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Columbia  ^nitjer^fftp 
intlieCitpoflmjgork 

College  of  ptpsiictans:  anb  ^urgeon£( 

ililirarp 

^^^5^P^ 

Gipt  or 

RHOOt  ISLAND  MEDICAL SOCIEry 

Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/statecontroloftuOOchap 


FiSKE  Fund  Prize  Dissertation.    No.  XLIV. 


STATE    CONTROL   OF 
TUBERCULOSIS. 


CHARLES    V.     CHAPIN,     M.    D., 

Superintendent  of  Health  of  the  Chy  of  Providence. 


PKOVIDENCE : 

Snow  &  Farnham,  Printers, 
1900. 


THE  Trustees  of  the  Fiske  P\incl,  at  the  annual  meeting  of  the  Rhode 
Island  Medical  Society,  held  at  Providence,  Sept.  0,  1900,  announced 
that  they  had  awarded  a  premium  of  two  hundred  dollars  to  an  essay  on 

"  State  Control  of  Tuberculosis,"  bearing  tlie  motto  : 

"  Festina  lente." 

The  author  was  found  to  be  Ciiari.es  V.   Chapin,  M.  D.,  of  Provi- 
dence, R.  I. 

GEORGE  D.  HERSEY,  M.  D.,  Providence. 
GEORGE  F.   KEENE,  M.  D.,  Howard. 
WILLIAM  R.   WHITE,  M.  D.,   Providence. 

Triditees. 
HALSEY  De  wolf,  M.  D.,  Providence, 

Secretary  of  the  Trustees. 


The  State  Control  of  Tuberculosis. 


To  successfully  control  a  disease  it  is  necessary  to 
know  how  it  is  caused.  For  a  century  or  more,  many 
acute  observers  have  been  convinced  of  the  contagious 
character  of  tuberculosis.  Experiments  were  long  ago 
imdertaken  to  prove  its  communicability,  and  some  of 
them,  particularly  those  of  Villemin,  were  successful. 
The  intelligent  medical  ^vorld  was  not,  therefore,  un- 
prepared for  the  discoveries  of  Koch.  By  him  was 
discovered  the  essential  factor  in  the  causation  of  the 
disease.  His  experiments  were  a  complete  demon- 
stration that  the  disease  we  are  considering  is  due  to 
the  action  upon  the  tissues  of  the  tubercle  bacillus. 
The  bacillus  is  the  cause  of  the  disease.  Scores  of 
competent  observers  at  once  attempted  to  prove  or 
disprove  Koch's  views.  This  is  the  proper  fate  of 
every  important  discovery  and  of  every  alluring  error. 
Eighteen  years  have  passed,  and  no  person  able  to 
judge  denies  the  causative  relation  of  the  bacillus  to 
the  disease.  The  definition  of  the  disease  is  made  by 
the  facts.  Whatever  abnormal  condition  is  produced 
in  the  tissues  by  the  bacillus  is  tuberculosis. 

DISTRIBUTION    OF    THE    DISEASE. 

There  are  various  forms  of  tubercular  disease  occur- 
ring among  both  men  and  animals.  Of  the  forms  occur- 
ing  in  the  hmnan  species,  phthisis  is  the  most  common. 
It  is  generally  said  to  cause  one-seventh  of  all  deaths, 
but  that,  at  present,  is  scarcely  true,  for,  owing  to  the 


4  THE  statp:  control 

diminution  wliicli  has,  of  recent  year.s,  taken  place,  it 
does  not,  luider  favorable  conditions,  cause  more  than 
one-ninth  or  even  one-tenth  of  the  deaths.  It  is  diffi- 
cult to  determine  just  what  proportion  of  tubercular 
deaths  is  due  to  other  forms.  The  recent  Royal  Com- 
mission considered  that  al)out  one-quarter  of  tubercular 
diseases  are  not  phthisical.  In  Providence,  however, 
probably  not  over  15  per  cent,  are  non-phthisical.  It 
is  only  in  infancy  that  non-phthisical  forms  are  the 
most  prevalent.  In  Massachusetts,  under  one  year, 
the  non-phthisical  are  to  the  phthisical  as  116  to  11, 
and  Ijetween  the  first  and  fifteenth  year,  as  61  to  37'. 
The  non-phthisical  forms  of  the  disease  Ave  are  consider- 
ing are  retiu^ned,  sometimes,  as  "  tuberculosis,"  some- 
times as  tubercular  meningitis,  laryngitis,  etc. ;  again, 
as  hydrocephalous  or  lu])us.  Diseases  of  the  bones  and 
joints  and  intestinal  diseases,  especially  in  young  chil- 
dren, are  very  commonly  due  to  tubercular  infection. 
In  this  connection,  it  must  be  remembered  that  the 
deaths  do  not  by  any  means  represent  all  the  cases. 
Tuberculosis  is  not  infrequently  recovered  from,  though 
it  leaves  its  traces  in  the  organism.  Marks  of  tuber- 
cular infection  are  frequently  found  at  the  autopsy  of 
persons  who  have  died  of  other  affections.  Knopf 
says  that  traces  of  tuberculosis  are  found  in  25  per 
cent,  of  all  such  autopsies.  In  the  New  York  hospitals 
it  runs  as  high  as  30  per  cent.,  and  in  Vienna,  where 
the  disease  is  particularly  prevalent,  the  marks  of 
tuberculosis  are  said  to  l)e  found  in  (S5  per  cent,  of  all 
autopsies. 

A  very  large  number  of  species  of  the  lower 
animals  are  also  suljject  to  tuberculosis,  particularly 
domestic  animals  oi"  wild  animals  kept  in  confinement. 


OF    TUBERCULOJSIS.  5 

To  tiiljerculosis  acquired  iiatiinilly.  the  bovine  species 
appears  to  be  more  susceptible  than  are  other  animals. 
Next  in  susceptibility  among  the  domestic  animals  are 
swine.  Goats  and  fowls  also  contract  it,  and  sheep 
sometimes  have  it.  It  is  very  readilv  inoculated  into 
rabbits  and  guinea  pigs.  Parrots  and  canaries  have 
been  known  to  have  it,  but  it  is  very  difficult  to  pro- 
duce it  in  sparrows.  The  carnivorous  animals  are  very 
slightly  susceptible,  though  wild  animals  kept  in  con- 
finement, as  lions  and  tigers,  occasionally  contract  it. 
As  a  rule  mammalia  are  more  susceptible  than  the 
other  vertebrate  classes.  Birds  come  next,  and  it  has 
only  recently  been  discovered  that  fishes  sometimes 
have  this  disease.  Even  in  the  Ijovine  species,  tuber- 
culosis is  not  uniiormh^  distributed.  The  statistics  of 
the  Leipsig  slaughter-house  for  1895  showed  that  of 
oxen  28.14  per  cent,  had  tuberculosis  ;  of  heifers,  20.35 
per  cent. ;  of  cows,  43.51 ;  of  ])ulls,  23.83,  and  of  calves, 
0.18. 

It  would  be  of  very  great  interest  to  know  just  how  ex- 
tensively tuberculosis  prevails  among  the  herds  of  this 
and  other  civilized  countries,  but  we  have  no  accurate 
statistics,  at  least,  for  this  country.  It  is  probably 
much  more  common  in  certain  parts  of  Europe  than  it 
is  in  any  part  of  tbe  United  States.  It  is  said  that  27 
per  cent,  of  all  animals  slaughtered  in  Saxony  have 
tuberculosis.  No  such  figures  have  been  obtained  in 
this  country,  though,  in  Philadelphia,  it  is  said  that  a 
year  or  two  ago  20  per  cent,  of  the  slaughtered  animals 
were  infected.  In  the  New  York  slaughter-houses,  7 
per  cent,  have  been  found  infected,  and,  at  the 
Brighton  abattoir,  5  per  cent,  of  Eastern  cattle.  In 
Massachusetts,  wdiere   the   tuberculin  test  is  required 


6  THE    STATE    CONTHOL 

for  all  animals  imported  into  the  State,  it  is  said  that 
10  per  cent,  of  the  animals  tested  ])rove  to  he  tuher- 
ciilons.  There  is  ahnost  no  tnherculosis  among  the 
eattle  on  the  ranges  in  the  West,  and  the  most  is  found 
among  the  dairy  herds  which  sn])ply  the  Eastern  cities. 
Veterinarians  seem  to  he  very  generally  agreed  that 
tuberculosis  among  cattle  has  increased  considei'ahly 
during  the  last  few  years,  at  least  until  steps  began 
to  be  taken  for  its  eradication. 

It  has  been  suggested  that  the  tuberculosis  of  man 
and  of  the  other  animals  may  not  be  identical.  The 
bacilli  which  are  found  in  the  lesions  of  the  different 
species  are  not  always  exactly  the  same.  There  are 
slight  morphological  and  cultural  differences  between 
the  bacilli  usually  found  in  man  and  cattle.  The 
bovine  bacilli  are  usually  slightly  shorter  and  straighter, 
and  their  growth  upon  artificial  media  is  less  luxuriant, 
and  these  characters  are  quite  consistent  through 
several  generations  of  artificial  cultures.  There  are 
some  differences,  also,  in  regard  to  the  degree  of  viru- 
lence of  the  different  forms.  Theobold  Smith,  who 
has  given  special  attention  to  this  subject,  has  rarely 
found  the  bovine  type  in  human  subjects.  He  is, 
however,  far  from  holding  that  the  different  types 
may  not  pass  from  one  species  to  another.  Recent 
bacteriological  work  seems  to  show  that  the  morpho- 
logical and  physical  characters  of  most  species  of 
bacteria  can  be  considerably  changed,  usually  slowly, 
sometimes  raj^idly,  by  change  of  environment.  Thus, 
although  ordinarily  the  tubercle  bacillus  does  not  grow 
at  a  temperature  below  98*^  F.,  it  can  be  made  to  do 
so  by  careful  manipulation,  hy  gradually  reducing  the 
temperature  for  successive  generations.     The  general 


OE    TUBERCULOSIS.  7 

opinion  seems  to  be  that  such  slightly  different  forms 
as  the  limnan  and  l)ovine  bacillus  may  readily  pass  one 
into  the  other ;  moreover,  as  will  be  seen,  there  is  con- 
siderable evidence  to  show  that  the  disease  is  fre- 
quently transmitted  from  animals  to  man  and  not 
rarely,  vice  versa.  There  are  many  who  go  so  far  as  to 
think  the  evidence  shows  that  almost  all  human  tul^er- 
culosis  is  derived  from  the  lower  animals.  One  argu- 
ment for  this,  which  has  been  elaborately  presented,  is 
that  the  prevalence  of  the  disease  in  the  human  and 
bovine  species  is  co-extensive,  and  that  human  tuber- 
culosis is  not  found  where  there  are  no  domestic 
animals  affected  with  this  disease.  This  argument  will 
not,  however,  bear  close  investigation,  for  right  in  our 
own  section  of  the  country,  at  Nantucket  and  on  Cape 
Cod,  tuberculosis  among  cattle  is  very  rare,  but  is  ex- 
tremely common  among  human  beings. 

While  the  bacillus  is  the  essential  cause  of  this  dis- 
ease, there  are,  of  course,  many  other  factors  in  its 
production.  There  are,  probably,  differences  of  indi- 
vidual susceptibility  to  all  infectious  diseases,  and  this 
difference  appears  to  he  very  marked  as  regards  tuber- 
culosis. It  has  long  been  believed  that  a  poorly 
nourished  body  is  one  of  the  chief  factoi's  in  the  caus- 
ation of  individual  cases  of  the  disease.  There  are 
certain  physical  characteristics  which  are  difificult  to 
define,  but  not  so  dithcult  for  the  practiced  eye  of  the 
physician  to  recognize,  which  are  indicative  of  a  tuber- 
cular disposition.  It  is  through  the  inheritance  of 
such  characters  that  heredit}'  has  its  share  in  the 
spread  of  this  disease.  The  disease  itself  is  rarely  in- 
herited, but  the  susceptibility  to  it  frequently  is.  It 
is  always  difficult  to  demonstrate  the  relative  import- 


0  THE    STATE    CONTROL 

aiice  of  heredity  and  eiiviroiinient,  but  ino.st  physicians 
have  seen  so  many  cases  where  tlie  influence  of 
heredity  appeared  to  be  very  great,  that  most  are  con- 
vinced that  this  is  a  very  important  factor.  Law  re- 
ports an  interesting  case  where  he  found  eleven  cows  of 
a  certain  herd  infected  with  tuberculosis.  These  eleven 
were  all  of  one  family,  distinct  from  the  rest  of  the 
herd.  The  actual  inheritance  of  tuberculosis  does 
sometimes  take  place.  Calves  killed  immediately  after 
birth  are  sometimes  found  to  be  tuberculous.  In  the 
Munich  slaughter-house  this  is  found  only  once  in 
100,000  cases,  and  in  Lyons  the  proportion  was  not 
much  greater.  Most  European  veterinarians  consider 
it  a  great  rarity.  It  appears  to  have  been  seen  more 
often  in  the  United  States.  The  Maine  cattle  commis- 
sioners report  having  met  with  it  in  sixty  cases. 

What  are  called  unhygienic  surroundings,  over- 
crowding, impure  air,  especially  dust-laden  air,  lack  of 
sunlight,  insutficient  clothing,  and  improper  food  are 
all  good  friends  of  the  tubercle  bacillus.  The  State 
may  do  much  to  improve  the  conditions  of  life,  and,  in 
this  way,  indirectly  control  the  spread  of  tubercular 
disease,  but  it  is  not  this  indirect  form  of  State  control 
which  will  be  considered  in  this  paper. 

METHODS    OF    EXTENSION. 

That  tuberculosis  is  contagious  was  incontestably 
demonstrated  by  Koch.  The  difticulty  of  demonstrat- 
ing the  contagiousness  of  a  disease  clinically  is  very 
great.  For  years  physicians  have  felt  that  such  evi- 
dence was  very  strong,  and,  not  long  since,  the  com- 
mittee on  collective  investigation  of  the  British  Medical 
Association  attempted  to  secure  evidence  which  would 


OF    TUBERCULOSIS.  9 

satisfuctorih"  prove  or  disprove  the  point  at  issue,  ))ut, 
altli(nigh  several  hundred  cases  were  reported,  it  was 
sliown  in  an  ahle  pjiper  l)y  Langstaff  that  they  were 
not  much  more  numerous  than  the  coincident  affection 
of  the  two  persons  could  be  expected  to  occur,  accord- 
ing to  the  law  of  chance.  It  has,  how^ever,  been 
proved  beyond  question  that  among  animals  the  dis- 
ease ma}^  be  and  is  transmitted  from  one  individual  to 
another.  The  identity  of  the  lesions  in  man  and 
animals,  and  the  fact  of  the  universal  presence  of  the 
bacillus  in  these  lesions  renders  it  certain  that  tuber- 
culosis in  man  also  is  a  contagious  disease.-  There  can 
be  no  question  that  tuberculosis  is  only  caused  hy  the 
tubercle  bacillus,  and  that  the  tubercle  bacillus  does 
except  under  extraordinary  conditions,  not,  grow  out- 
side of  the  human  body. 

In  order  to  grow  tlie  tubercle  bacillus,  it  is  necessary 
to  exercise  great  care  in  the  preparation  of  the  culture 
medium.  Furthermore,  growth  will  very  rarely  take 
place  except  at  the  temperature  of  the  body.  The 
conditions  are  such  that  it  can  be  said  to  Ije  strictly 
])arasitic  in  its  habits  of  life.  If  any  animal  becomes 
infected,  the  germs  must  have  been  derived  mediately 
or  immediately  from  some  other  animal.  While  the 
bacilli  do  not  grow  outside  of  the  l^ody,  they  may  re- 
main alive  for  a  considerable  length  of  time.  They 
are  not,  however,  so  resistant  to  destructive  agencies 
as  are  many  bacteria.  Exposure  to  sunlight  very 
speedily  destroys  them,  sometimes  in  a  few  minutes. 
Drying,  however,  does  not  destroy  them.  Dried 
sputum  has  been  shown  to  retain  its  virulence  for 
three  months,  and  doubtless,  at  times,  will  retain  it 
for    a   much    longer    period.     The  bacillus  is  readily 


10 


THE    STATE    COXTROL 


killed  by  beat,  exposure  to  a  temperature  of  00'^  C.  for 
15  minutes  proving  fatal.  It  is,  bowever,  quite  re- 
sistant to  dry  beat.  It  is  killed  by  disinfectants  of 
ordinary  strengtb,  but  tbe  action  of  corrosive  sublimate 
upon  sputum  requires  a  strengtb  of  1  to  500,  as  it 
forms  inert  compoiuids  witb  tbe  allnmiinous  matter  of 
tbe  sputum. 

Tbe  presence  of  tbe  tubercle  bacillus  in  tbe  dust  of 
bospitals,  cburcbes,  tbeatres,  scbools,  dwellings,  and 
streets  bas  been  mucb  discussed.  A  considerable 
number  of  investigations  bave  been  made  to  determine 
its  presencein  different  localities.  Some  years  since, 
Webb,  in  Pbiladelpbia,  found  it  in  tbe  air  of  places  of 
public  assembly.  Hance  found  it  in  tbe  air  of  Adiron- 
dack sanatoria,  killing  5  out  of  25  Guinea  pigs  wbicli 
be  inoculated.  Gardiner  did  not  find  it  in  8  tests 
made  at  a  Colorado  Springs  botel.  Tbe  most  careful 
and  complete  experiments  were  made  by  Cornet.  Tbe 
following  table  shows  tbe  results  of  bis  work  : 


Places  fko.m   w  uki 

Sami'les  of  DrsT 

WEKE  Taken. 


In  the  seven  hospitals 

In  the  three  insane  asylums.. . . 

In  two  prisons 

Inhalation  experiment  room.  . . 

Private  patients 

Poliklinik,  orphan  asylum,  etc 

Surgical  halls 

Streets  and  hygienic  institute.  . 
Streets  alone 


Totals :  ..    892      59 


94 
33 
14 

4 

170 

28 

8 
41 


196 


!£  cS  C 

O  !3-~ 
—  0)  C 

o  ^  S 

•O  Si  2 
oj  QJ  C 


72 

19 

6 

2 

125 

14 
1 

16 


255 


76.6 
67.5 
42.0 
50.0 
73.5 
50.0 
12.5 
39.0 
55.0 


14 

8 

2 

25 

14 


65.05    137 


OF    TrBERCULOSIS.  11 

From  this  table  we  can  make  the  dediietion  that  the 
danger  to  the  inocuLated  jinimals  of  tnbercular  infec- 
tion was  in  tlie  hospitals  47.6  per  cent.,  in  the  insane 
asylmns  17.G,  and  in  private  dwelling  houses  of  con- 
sumptive patients  43.6.  Cornet's  experiments  showed 
that  invarial)ly,  where  the  tul)ercle  l)acillus  was  found 
the  patients  did  not  restrict  themselves  to  the  use  of  a 
spit-cup,  but  expectorated,  also,  upon  the  floor  or  into 
a  pocket  handkerchief.  He  succeeded  only  in  a  single 
instance  in  making  an  animal  tul^erculous  where  the 
patients  had  surely  restricted  themselves  to  the  use  of 
the  spit-cup.  Twenty-nine  of  his  samples  of  dust  were 
taken  from  places  not  especially  frequented  l^y  tuber- 
culous persons,  such  as  general  hospitals,  an  orphan 
asylum,  the  hygienic  museum,  public  stairways,  and, 
in  nine  instances,  from  streets.  These  samples  were 
inoculated  upon  873  animals,  not  one  of  which  became 
tuberculous.  These  experiments  tend  to  make  it  quite 
certain  that  the  tubercle  l^acillus  is  not  very  widely 
distributed.  There  is  not  much  chance  of  meeting 
with  it  except  in  the  close  neighborhood  of  a  consump- 
tive or  in  apartments  wdiich  have  been  for  some  time 
occupied  by  a  consumptive.  Further  investigations  of 
the  distribution  of  the  tubercle  bacillus  would  be  very 
desirable,  but  from  those  already  made  and  from  what 
we  know  clinically  of  the  spread  of  this  and  other  com- 
municable diseases,  it  is  entirely  likely  that  the  con- 
clusions of  Cornet  would  be  fully  verified.  Strauss 
examined  the  saliva  of  a  number  of  persons  who  had 
the  care  of  those  sick  wdth  phthisis,  and  found 
bacilli  present  in  a  few  of  them.  It  has  been  demon- 
strated by  very  many  observers  that  the  expired  breath 
contains  no  bacteria  of  any  kind.     AVith  the  conditions 


12  THE    STATE    COXTUOL 

that  pre\ail  in  coughing,  sneezing,  and  sometime.s  even 
in  talking,  it  is  otherwise.  Under  such  conditions 
there  appears  to  be  a  fine  spray  thrown  out,  in  the 
droplets  of  which  bacteria  may  be  found,  and  tubercle 
bacilli  have  thus  been  shown  to  be  given  off  from 
phthisical  patients.  This  spray,  however,  extends 
only  a  few  feet  from  the  patient.  Experiment,  then, 
seems  to  shoAv  that  ordinarily  quite  close  contact  is 
necessary  for  contagion  in  this  disease.  Clinical  evi- 
dence also  supports  this  view.  Of  course  in  the 
majority  of  cases  of  marital  contagion  wdiicli  have  been 
recorded,  the  intimacy  was  close.  Of  213  cases  of 
probable  contagion  collected  by  Martin,  one-half  were 
marital.  Cornet's  investigation  of  the  Catholic  Nurs- 
ing Orders  in  Germany,  before  precautions  were  taken 
to  prevent  contagion,  showed  that  a  very  large  number 
succumbed  to  this  disease.  Of  2,099  deaths,  1,320 
were  due  to  tuberculosis,  and  of  course  in  all  these 
cases  there  was  close  contact  between  the  nurse  and 
the  patient. 

The  evidence,  then,  seems  to  be  very  strong  that 
the  tubercle  Ijacillus  is  not  widely  distributed  outside 
of  the  body,  that  it  is  not  found  in  the  air  except 
close  to  tlie  patient,  and  not  then  in  any  quantity  if 
proper  precautions  are  taken.  Contagion  is  found 
only  in  the  air  close  to  the  patient,  on  the  patient 
himself,  and  on  articles  wdiich  the  patient  or  his  secre- 
tions have  touched.  Prol)ably  the  same  conditions 
are  necesary  for  contagion  from  animals. 

There  are  three  avenues  of  infection  :     , 

First,  tkroiKjh  the  skin. 

There  are  a  number  of  cases  of  persons  who  have 
been   inoculated    through    the    skin.     The    celebrated 


OF    TUBERCULOSIS.  13 

Laennec  died  of  pulmonary  tiiberculoisis  which  was 
thought  to  be  contracted  through  the  accidental  inocula- 
tion of  his  finger  at  an  autopsy.  A  more  recent  case  and 
one  concerning  which  there  is  little  doubt  was  reported 
by  Pfeiffer,  who  tells  of  a  veterinarian  whose  finger 
was  inoculated,  whose  joints  later  became  involved,  and 
who  finally  died  of  the  pulmonary  form  of  the  disease. 
Law  and  Ravenal  both  report  cases  of  the  accidental 
infection  of  the  hands  of  veterinarians,  and  in  the  case 
reported  by  the  former,  the  extension  of  the  disease 
was  only  prevented  by  amputation.  Knopf  had  a 
similar  case  in  a  nurse  who  l^ecame  inflected  while 
dressing  a  tuberculous  wound.  Ernst  rejDorted  a  case 
of  infection  of  the  tongue.  Heron,  in  evidence  pre- 
sented to  the  Connnittee  on  Collective  Investigation, 
in  1890,  reported  seventy-three  articles  dealing  with 
this  subject.  A  considerable  number  are  also  reported 
by  Senn  in  his  surgery.  Lindeman,  Jacobi,  and  Knopf 
report  a  numl^er  of  cases  of  infection  through  the  rite 
of  circumcision.  There  are  also  on  record  cases  due 
to  the  common  practice  of  tattooing. 

In  can  thus  be  seen  that  the  danger  of  infection 
through  the  skin  is  a  real  one.  Nevertheless,  the  evi- 
dence shows  that  the  danger  is  very  slight,  and  may  be 
neglected  in  any  measures  undertaken  for  the  state 
control  of  the  disease. 

Second,  throiKjh  the  respiratory  tract. 

It  is  generally  believed  that  this  is  by  far  the  most 
common  avenue  of  infection.  This  view  is  based 
chiefly  upon  the  facts  that  the  pulmonary  is  the  most 
common  form  of  the  disease,  and  that  the  lungs  are,  in 
such   cases,  involved  to  a  very  much  greater  degree 


14  THE    STATE    CONTROL 

than  are  other  organs.  It  is  pro])a])le  that  in  the  main 
this  reasoning  is  correct.  But  it  does  not  necessarily 
follow  that  because  the  lungs  are  chiefly  involved  that 
they  were  the  seat  of  the  primary  infection.  Wood- 
head  has  shown  that  infection  through  the  intestinal 
wall  may  leave  very  few  traces  there,  the  most  im- 
portant lesions  being  subsequently  found  elsewhere  in 
distant  organs,  such  as  the  thoracic  glands. 

From  the  time  of  Koch,  many  experiments  have 
been  tried  to  produce  pulmonary  tuberculosis  l)y  the 
inhalation  of  dust  containing  the  living  bacilli.  Most 
of  these  experiments  have  been  unsuccessful.  The 
attemj)t  has  also  Ijeen  made  to  induce  it  by  the  inhala- 
tion of  spray,  such  as  was  referred  to  as  given  off  from 
consumptive  patients  during  sneezing  and  coughing. 
These  experiments  have  been  more  often  successful, 
but  not  invariably  so.  It  seems  to  be  quite  certain 
from  the  experiments  of  Cornet  that  have  ))een  referred 
to,  and  from  the  observations  of  many  careful  investi- 
gators, that  pulmonary  infection  is  not  readily  induced. 
The  breating  of  a  few  bacilli  by  a  healthy  person  is  not 
likely  to  cause  the  disease.  Chance  contact  with 
bacilli  in  the  dust  of  the  street,  which  has  Ijeen  much 
dreaded,  probably  rarely  gives  rise  to  the  disease. 
Most  of  those  who  have  studied  the  contagion  of  this 
disease  clinically,  as  tlie  Committee  on  Collective  In- 
vestigation, Heron,  Martin,  Russell,  and  Cornet,  believe 
that  close  and  prolonged  contact  is  necessary,  in  most 
cases,  to  produce  infection.  Infection  is  not  carried 
far  by  the  air.  This  accords  with  the  known  facts  in 
regard  to  the  transmission  of  other  diseases.  Scarlet 
fever  and  diphtheria  do  not  pass  from  one  tenement 
to  another  in  the  same  house  unless  there  is  an  actual 


OF    TUBERCULOSIS.  15 

passage  of  infected  persons.  The  carrying  of  con- 
tagion from  the  sick  to  the  well  by  a  third  person  is 
not  common.  Physicians  rarely  carry  contagions  dis- 
eases. 

It  seems  most  reasonable  to  jjelieve  that  the  majority 
of  cases  of  consumption  are  due  to  primary  infection 
of  the  pulmonary  tissue,  but  this  is  by  no  means 
proved.  It  may  be  that  future  investigation  may 
change  this  view.  Even  now,  there  are  man}'  who 
hold  to  the  contrary.  Knopf  believes  that  fully  as 
many  cases  of  tuberculosis  receive  their  infection 
through  the  alimentary  canal  as  through  the  respira- 
tory mucous  membrane. 

Third,  through  the  a/lnteutari/  tract. 

Medical  literature  contains  the  record  of  many  cases 
of  tuberculosis  which  are  presumably  due  to  infection 
•  through  the  alimentary  canal,  usually  from  the  in- 
gestion of  milk  supposed  to  be  tuberculous.  Some- 
times, however,  as  in  cases  reported  by  Sherman  of 
San  Francisco,  the  infection  was  caused  by  kissing  or 
putting  infected  articles  in  the  mouth.  In  many  of 
these  reported,  the  evidence  of  the  source  of  the  in- 
fection was  bv  no  means  certain,  and  in  not  a  few  of 
them,  infection  through  the  alimentary  canal  was  a 
possibility  rather  than  even  a  probal^ility.  Ernst  re- 
ceived 1,013  answers  to  a  circular  sent  out  to  physicians 
and  veterinarians,  asking  for  reports  of  cases  of  tuber- 
cular infection  through  the  medium  of  milk.  Although 
(juite  a  number  of  cases  were  reported,  it  was  not 
possible  in  many  of  them  to  exclude,  with  any  degree 
of  certainty,  other  sources  of  infection.  It  is  thus 
seen   that   clinical    evidence   of  infection  through  the 


16  THE    STATE    CONTROL 

alimentary  canal  is  not  very  strong.  But  such  a  result 
might  well  l)e  expected.  It  is  ditticult  to  trace  con- 
tagion in  any  disease,  and  particularly  so  in  tubercu- 
losis, a  disease  which  is  slow  in  developing,  and  which 
is  extremely  common. 

There  is  certain  statistical  evidence  which  indicates 
that  infection  frequently  takes  place  through  the  ali- 
mentary canal,  probably  by  the  ingestion  of  milk. 
Tubercular  disease  of  the  digestive  organs  is  much 
more  frequent  among  young  children  and  particularly 
infants  under  the  age  of  one  year  than  at  any  other 
age.  Such  children,  of  course,  live  largely  on  a  milk 
diet,  and  if  tuberculosis  is  transmitted  through  the 
medium  of  milk,  we  should  expect  intestinal  and 
similar  forms  of  the  disease  to  be  more  prevalent  at 
these  ages.  Again,  statistics  show  that  intestinal 
forms  of  tuberculosis  have  not,  of  late  years,  diminished 
nearly  as  much  as  has  the  pulmonary  form.  The  re- 
port of  the  Royal  Commission  states  that  tuberculosis 
among  children  under  one  year  of  age  has  actually 
increased  in  England  and  Wales.  In  most  places,  how- 
ever, cases  in  infants  have  diminished  somewhat  in 
frequency.  It  is  not,  of  course,  to  be  assumed  that  all 
cases  of  tuberculosis  in  young  children  are  due  to  milk 
infection.  Yet  as  there  is  good  reason  to  believe  that 
tuberculosis  among  dairy  animals  has  of  late  years  in- 
creased, the  fact  that  tuberculosis  retains  a  stronger 
hold  in  infancy  than  in  later  life,  tends  to  support  tlie 
view  that,  in  the  young,  milk  infection  is  no  incon- 
siderable source  of  the  disease. 

The  following  table  illustrating  the  distribution  of 
the  different  forms  of  tuberculosis  in  Glasgow,  also 
throws  some  light  on  this  sul)ject : 


OF    TUBERCULOSIS. 
1890-5.     GLASGOW  Death  Rates  Per  100,000. 


17 


tr. 

< 

•2 

Other  Tubercular 
Diseases. 

All  Tubercular 
-  Diseases. 

i 

CORRECTED   FOR  AGE 
DISTRIIU'TION. 

City 

Average  of  three  districts 
with 

(1)  Highest  death-rate  from 
Phthisis 

(2)  Phthisis  death  rate  near- 
est mean  of  city 

(3)  Lowest  Phthisis  deatli- 
rate 

2,336 

3,256 
2,197 
1,692 

230 

328 
213 
157 

91 

125 
95 
67 

321 

454 
309 
225 

28.3 

27.5 
30.9 
30.2 

It  is  seen  that  all  tubercular  deaths  most  prevail 
where  the  general  death  rate  is  greatest,  and  there  also 
phthisis  is  most  prevalent,  but  the  other  tubercular 
diseases  are  relatively  less  prevalent  than  in  other  dis- 
tricts where  there  is  not  only  less  phthisis,  but  a  much 
better  condition  generally,  as  is  indicated  by  the 
general  death  rate.  It  can  scarcely  be  maintained, 
therefore,  that  the  other  forms  of  tubercular  disease 
occur  as  a  direct  result  of  the  frequency  of  infection 
afforded  by  the  prevalence  of  phthisis.  Chalmers  who 
prepared  tlie  above  table  states  that  in  the  l)etter  class 
districts  there  is  a  greater  consumption  of  milk  than  in 
the  slums,  where  the  other  tubercular  diseases  form  a 
relatively  smaller  proportion  of  the  tul)erculous  death 
rate. 

Woodhead  states  that  of  127  cases  of  tuberculosis  in 
children,  in  which  autopsies  were  made,  the  mesenteric 
ulands   were   involved  in  100.     He  assumes  from  this 


18  THE    STATE    CONTHOL 

that  the  source  of  iiit'eetioii  in  these  100  cases  was,  in 
all  probability,  through  the  intestines.  In  fact,  in 
many  cases,  he  conld  trace  the  infection  from  the  in- 
testinal wall  up  through  the  mesenteric  glands  to 
distant  organs  of  the  Ijody.  Woodhead  also  believes, 
from  pathological  e\idence,  that  infection  not  rarely 
takes  place  through  the  tonsils,  this  often  being  the 
soiuTe  of  the  tul)ercTdar  infection  of  the  cervical 
glands. 

A  great  deal  of  experimental  work  has  been  done 
upon  the  jiroduction  of  tuberculosis  hy  way  of  the 
alimentary  canal.  A  good  many  examinations  have 
been  made  to  determine  the  frequency  Avith  which 
tubercle  bacilli  may  he  expected  in  the  milk  supply. 
There  has  been  much  discussion  as  to  the  occurrence 
of  the  bacilli  in  the  milk  of  tul)erculous  animals.  It 
has  been  claimed  hy  some  that  they  will  not  ])e  found 
in  the  milk  unless  the  udder  is  iuAohed  ;  Init  it  has 
been  shown  that  this  is  not  true.  Milk  is  much  more 
likely  to  Ije  tuberculous  when  the  udder  is  seiiously 
involved,  Init  it  does  occur  when  no  signs  of  disease 
can  be  detected.  Ernst  examined  microscopically  the 
milk  of  thirty-six  animals,  which  were  tuberculous  but 
had  sound  udders  and  found  bacilli  in  the  milk  of 
twelve.  They  were  found  equally  in  the  milk  itself 
and  in  the  cream.  In  fifty-six  samples  of  milk  and 
thirtv-three  sami)les  of  cream,  taken  from  the  general 
supply  of  the  Cit}'  of  Boston,  no  bacilli  Mere  found  on 
miscroscopical  examination.  The  most  certain  way  of 
detecting  the  presence  of  tubercle  bacilli  in  milk  or,  in 
fact,  in  any  material  is  by  inoculating  the  same  into 
animals.  Ernst  found  in  twenty-five  inoculation  ex- 
periments performed  with  milk  from  the  Boston  supply, 


OF    TIBEIICULOSIS.  19 

tliut  three  gave  jKJsitive  results.  Kaiitliaek,  experi- 
menting in  Camljridge,  England,  found  infection  in 
nine  out  of  sixteen  dairies  supplying  that  town.  The 
milk,  however,  was  not  very  thoroughh'  impregnated, 
as  only  a  very  few  of  the  animals  inoculated  succmnljed 
to  the  disease.  It  has  been  shown  experimentally  in 
reii;ard  to  the  tuljercle  Ijacillus  in  milk  as,  indeed,  it 
has  to  the  cultures  of  many  other  bacteria,  that  the 
greater  the  dilution  and  the  smaller  the  dose,  the  less 
the  chance  of  infection. 

Kanthack.  as  well  as  p]rnst,  has  shown  that  the 
Ijacilli  are  found  in  cream  as  well  as  in  the  whole 
milk,  l)ut  when  milk  is  put  through  a  centrifugal 
machine,  the  larger  ptirt  of  the  bacilli  are  renio\ed  in 
the  sediment.  Experiments  in  Germany  have  shown 
that  butter  may  contain  tubercle  bacilli. 

A  number  of  other  experimentors,  as  well  as  Ernst, 
"have  found  1)acilli  in  milk,  when  the  udders  were 
apparently  healthy,  and.  in  fact,  when  tuberculosis 
could  only  be  detected  by  the  tuljerculin  test.  It 
must  l)e  admitted,  then,  that  we  have  pretty  strong- 
evidence  that  if  a  dairy  herd  has  in  it  tuberculous 
animals,  the  milk  fnjm  that  herd  stands  a  very  good 
chance  of  being  infected.  The  more  disease  there  is 
in  the  herd,  and  the  farther  advanced  it  is,  the  greater 
the  danger.  ~- 

The  fact  that  tul)ercle  bacilli  are  found  in  milk  and 
may,  by  injection  into  the  lower  animals,  cause  tuber- 
culosis, does  not  prove  that  milk  would  cause  the  disease 
if  taken  into  the  alimentary  canal.  Of  course,  many 
feeding  experiments  have  Ijeen  undertaken  with  milk 
and  other  products  from  tuberculous  animals.  These 
have  not  always  been  successful.     Smith,  Law,  Nocard, 


20  THE    S'I'ATE    COXTL'OL 

and  McFadyeaii  coidd  not  infect  rabbits  and  gninea 
pigs  by  feeding  tbem  witb  milk  winch  was  known  to  be 
tubercnlons.  Pencil,  for  two  months,  fed  two  pigs 
with  milk  that,  by  injection,  prodnced  tnbercnlosis  in 
rabbits,  withont  prodncing  any  effect  npon  the  pigs. 
Gerlach  also  was  sometimes  snccessfnl  and  sometimes 
not.  On  the  other  hand,  many  feeding  experiments 
have  been  snccessfnl.  Ernst,  nsing  milk  from  tuber- 
cnlons animals  with  apparently  healthy  udders,  pro- 
dnced tu])erculosis  in  two  out  of  forty-eight  calves  fed 
with  it.  He  also  infected  five  out  of  twelve  pigs ;  and, 
in  another  series  of  experiments,  eight  out  of  tAventy- 
one  calves.  Law  reports  three  calves  which  had  milk 
from  sound  udders,  but  became  tuberculous.  Pearson 
fed  pigs  with  milk  known  to  be  tuberculous,  and  the 
animals  apparently  got  fat  upon  it,  Init  wdien  killed 
were  found  to  Ije  infected.  He  saj^s  instances  are  not 
rare  in  which  calves  and  swine  fed  with  skim  milk 
from  a  creamery,  have  developed  tul^erculosis  on  farms 
that  are  otherwise  free  from  this  disease. 

The  evidence,  then,  seems  to  ))e  that  milk  of  tuber- 
culous animals  is  quite  likely  to  be  infected,  and  that  if 
infected  it  frequently  produces  tuberculosis  in  other 
animals,  even  of  a  different  species,  wliicli  partake  ui 
it.  If  milk  can  infect  human  lacings  as  it  does  calves 
and  swine,  it  is  certainly  dangerous  to  use  in  a  raw 
state  the  milk  from  tuberculous  animals.  While  we 
have  no  incontrovertible  evidence  that  bovine  tul)er- 
culosis  is  thus  transmitted  to  man,  it  is  extremely 
probable  that  it  is  so.  We  certainly  have  very  little 
evidence  that  it  is  not,  and  it  would  require  prett}- 
strong  evidence  to  show  that  a  disease  which  can  l)e 
carried    over    from    cows    to     swine,    rabbits,    guinea 


OF    Tl'BEROULO.SIS.  21 

pigs  and  iiiaiiy  other  species,  cannot  he  transmitted  to 
Mian. 

There  has  jjeen  a  great  deal  of  discussion  as  to  the 
danger  from  the  nse  of  meat  from  tuberculous  animals. 
As  the  tubercle  ))acillus  is  killed  by  a  moderate  deo;ree 
of  moist  heat,  we  can  probably  safely  assume  that,  in 
the  majority  of  cases,  even  if  Ijacilli  are  present  in 
meat,  they  will  be  destroyed  by  cooking.  Experi- 
ments, however,  to  substantiate  this  view,  are  much  to 
])e  desired.  In  cases  where  the  lungs  chiefly  are  in- 
volved and  the  disease  has  not  progressed  too  far, 
there  is  not  much  likelihood  of  the  muscles  being  in- 
fected. In  fact,  it  is  very  unlikely  that  the  muscular 
tissue  itself  will  be.  infected  at  all,  but  when  there  is 
a  tendency  to  generalization  of  the  disease,  the  small 
glands  between  the  muscles  or  their  fasciculi  may  be 
involved.  In  such  cases^  it  would  be  dangerous  to  eat 
the  meat  in  a  raw  state.  Feeding  experiments  have 
been  conducted  upon  animals  with  little  positive  re- 
sult. Pencil  succeeded  in  infecting  two  pigs,  but  only 
after  feeding  them  for  v.  long  time.  Nocard  was  un- 
successful, as  also  were  Touissant,  Chaveau,  Arloing, 
Martin,  and  Yallin. 

Perroncito  fed  eighteen  pigs  for  from  three  to  five 
months  witli  condemned  tuberculous  meat,  but  none  of 
them  were  mfected.  It  would  appear  that  the  danger 
of  infection  by  meat  of  tul)ercidous  animals,  at  least 
unless  the  disease  has  progressed  very  far  and  is  much 
generalized,  is  not  very  great.  This  view  is  held  by 
many  leading  veterinarians.  It  is  the  practice  of  many 
not  to  condemn  the  flesh  of  tuberculous  animals  wlien 
the  disease  is  circumscribed.  In  Saxony,  the  govern- 
ment inspectors  permit  the  sale  of  the  larger  portion 


22  THE  .statp:  control 

of  the  llesli  of  tuhcrculoiis  ;iiiiiiials  killed  at  tlie  ahat- 
toirs.  This  meat,  however,  is  sold  on  its  merits  as 
eoming  from  tiihereuloiis  animals.  At  the  Brighton 
abattoir,  a  considerable  ])()rtion  of  the  tnberculous 
ammals  their  slaughtered  are  allowed  to  go  upon  the 
market. 

METHODS    OF    CONTROL    ALREADY    ADOPTED. 

Notificntion. 

An  important  step  in  the  control  of  other  infections 
diseases  is  the  report  of  cases  of  the  disease  to  the 
sanitary  authority.  This  is  desired,  in  order  that  the 
cases  may  be  studied  and  more  may  l)e  leai-ned  of  the 
way  in  which  the  diseases  are  spread,  and,  in  order 
that  any  necessary  methods  of  restriction  may  be 
applied  to  each  individual  case.  It  would  appear  that 
notification  is  as  necessary  in  tuberculosis  as  in  other 
diseases.  In  this  country,  notification  has  been  I'e- 
quired  in  a  numljer  of  states  and  cities.  Sometimes  it 
applies  to  phthisis  alone,  and  sometimes  to  all  tuber- 
cular diseases.  Notification  was  first  required  in  the 
City  of  New^  York,  and,  at  present,  is  a  requirement  of 
the  State  law  in  Maine  and  Michigan,  and  of  the  nruni- 
cipal  regulations  of  Alameda,  California  ;  Buffalo,  Cin- 
cinnati, the  City  of  New  York,  Salt  Lake  City,  and 
Yonkers.  In  these  regulations  the  requirement  ap})lies 
only  to  i)hthisis.  Tuljerculosis  is  to  l)e  reported  by  the 
State  law  of  Washington  and  by  the  regulations  of 
Asbury  Park,  Minneapolis,  San  Francisco,  and  Syracuse. 
A  recent  decision  of  the  Supreme  Court  of  Michigan 
has  affirmed  the  validity  of  the  law  in  that  state.  The 
followinjj:  is  the  rule  in  the  City  of  New  York  : 


OF    TIBERCULO.SIS.  Zo 

City  of  Xew  York,  Sanitary  Code,  1899,  Section  -ui : 

Section  lo^J.  That  pnhnonary  tuberculosis  is  herein'  dechired 
to  1)6  an  infectious  and  communicable  disease,  daiijierous  to  the 
public  health.  It  shall  be  the  duty  of  every  physician  in  this  city 
to  report  to  the  Sanitary  Bureau  in  writing  the  name,  age,  sex, 
occupation  and  address  of  every  jierson  having  such  disease  who 
has  been  attended  by  or  who  has  come  under  the  observation  of 
such  physician  for  the  lirst  time,  within  one  week  of  such  time. 
It  shall  also  I>e  the  duty  of  the  commissioners  or  managers,  or 
the  jirincipal,  superintendent  or  physician  of  each  and  every 
public  or  private  institution  or  dispensary  in  this  city  to  re})ort 
to  the  Sanitary  Bureau  in  writing,  or  to  cause  such  report  to  l)e 
made  by  some  })ro}»er  and  competent  ]>erson,  the  name,  age,  sex, 
occupation  and  last  address  of  every  person  afflicted  with  this 
disease  who  is  in  their  care  or  who  has  come  under  their  obser- 
vation within  one  week  of  such  time.  It  shall  be  the  duty  of 
every  jierson  sick  with  this  disease  and  of  every  person  in 
attendance  upon  anyone  sick  with  this  disease,  and  of  the 
authorities  of  public  and  private  institutions  or  dispensaries,  to 
observe  and  enforce  all  the  sanitary  rules  and  regulations  of  the 
Board  of  Health  for  preventing  the  spread  of  pulmonary  tu])er- 
culosis. 

These  laws  and  regulations  are  not  Avell  enforced. 
The  Secretary  of  the  State  Board  of  Health  of  Michi- 
gan informed  the  writer  that  probably  not  one-cjuarter 
of  all  the  cases  appearing  in  that  state  are  reported, 
and  the  board  of  health  of  Buffalo  report  that  notice  is 
rarely  recei^^ed  of  a  case  except  when  a  physician  sends 
in  sputinn  for  examination.  In  Michigan,  whenever  a 
case  of  consumption  is  reported  from  a  town,  the 
health  officer  is  required  to  fill  out  a  Ijlank,  stating  a 
large  nmnber  of  facts  in  regard  to  the  history  of  the 
case,  possible  sources  of  infection,  and  methods  taken  to 
]'estrict  the  disease.  On  the  death  of  the  patient,  or  re- 
covery, if  recovery  takes  place,  another  and  final  report 


24  THE    STATE    (ONTKOL 

is  to  be  made,  giving  fucts  of  inteniiediate  history  and 
whether  or  not  disinfection  was  done.  No  verv  valu- 
able results  have,  as  yet,  been  obtained  from  these 
investisrations,  as  onh*  a  few  of  the  rm-al  health  officers 
can  be  expected  to  1)e  skilled  enough  to  investigate  the 
cases  properly.  In  New  York  City,  careful  record  is 
kept  of  all  cases  reported,  and,  owing  to  the  active 
interest  taken  by  the  health  department  of  that  city, 
more  cases  are  reported  there  than  elsewhere,  so  that, 
of  late,  the  number  of  cases  reported  has  exceeded  the 
number  of  deaths.  A  careful  record  is  kept  of  all  cases, 
and  their  location  is  also  noted  on  a  map.  A  study  of 
this  map  has  shown  that  phthisis  prevails  to  a  much 
greater  extent  in  some  districts,  and  in  some  houses, 
than  it  does  in  others. 

Notification  presupposes  correct  diagnosis.  It  is 
generally  admitted  that  the  examination  of  the  sputum 
for  tubercle  bacilli  is  a  great  aid  to  diagnosis,  though 
it  is  to  l)e  feared  that  many  physicians  place  too  much 
dependence  upon  a  single  negative  finding.  To  assist 
plivsicians,  many  states  and  cities  olf'er  laboratory 
facilities  for  the  examination  of  the  sputum. 

Education. 

A  great  deal  has  been  done,  during  the  past  ten 
years,  to  educate  the  public  to  a  knowledge  of  the 
contagiousness  of  tuberculosis.  Prol)aldy  a  large  pro- 
portion of  intelligent  people  now  imderstand  that 
tul)erculosis  is  contagious.  A  large  part  of  this  work 
of  education  has  been  carried  on  h\  public  health 
officials,  particularly  those  engaged  in  laboratory 
work.  It  is  to  be  feared,  however,  that  some  of  the 
teachingr  has  oone  farther  than  the  facts  would  warrant. 


x^    '^'^"    c 


OF    TI'BERfrLOSIS.  ZO 

It  is  certain  that  tuberculosis  is  contagious,  but,  as  we 
have  seen,  the  exact  path  of  infection  is  not  perfectly 
known.  Nevertheless,  dou'inatic  statements  have  been 
verv  common  as  to  the  great  danger  of  breathing 
tuberculous  dust,  of  drinking  tuberculous  milk,  and 
of  eating  the  iiesh  of  tul)erculous  cattle.  It  is  true, 
however,  that  most  of  the  extravagant  statements  in 
regard  to  these  matters  have  not  emanated  directly 
from  the  Ijacteriologists.  The  pul)lic  press,  and  pseudo- 
scientists  generally,  have  sometimes  misunderstood  the 
meaning  of  the  work  of  scientific  investigators,  and 
have  made  too  much  of  what  are,  perhaps,  the  least 
important  patlis  of  contagion  in  this  disease.  The 
daily  press  is  of  great  assistance  in  sanitary  education, 
but  its  powers  should  be  called  into  play  with  consider- 
able care.  One  of  the  most  common  and  useful  means 
of  education  in  such  matters  is  the  distribution  of  cir- 
culars of  information.  Such  circulars,  explaining  the 
nature  and  methods  of  the  spread  of  tuberculosis,  have 
Ijeen  issued  hy  many  health  officials  and  l)y  the 
societies  for  the  suppression  of  tuberculosis.  One  of 
the  first  and  best  of  these  circulars  was  that  issued  by 
the  Board  of  Health  of  New.  York  City.  At  present, 
such  circulars  are  issued  by  the  State  Board  of  Healtli 
of  California,  Colorado,  Connecticut,  Delaware,  Indiana, 
Iowa,  Kentiu^ky,  Maine,  Massachusetts,  Michigan,  New 
Hampshire,  New  Jersey,  New  Mexico,  New  York,  Ohio, 
Rhode  Island,  South  Carolina,  Tennessee,  Texas,  \^ir- 
ginia,  AYest  Yirginia,  and  Wisconsin.  They  are  dis- 
tributed by  many  local  lioards  of  health  in  these  states 
m\(\  have  been  issued  by  cities  outside  of  the  states 
mentioned,  as  St.  Paul,  Minneapohs,  Chicago,  St.  Louis, 
and  Philadelphia.     In  New  York  City  they  are  sent  to 


26  I'lIE    STATE    CONTROL 

the  physicians  for  (Hstrihiition  to  their  patients,  and 
tliis  method  is  probaljly  followed  in  most  cities.  In 
Buffalo  tliev  are  sent  to  all  cases  reported,  or  to  tlie 
friends  of  tlic  patient.  In  New  York  City  the  sunnnei' 
corps  of  physicians  who  visit  among  the  poor,  distri- 
bute some  o(),(JO(J  annually.  In  Brookline,  Mass.,  one 
is  sent  to  every  family  in  the  town.  In  Minnea])olis 
one  form  of  the  circular  is  printed  upon  a  card  which 
is  to  be  hung  in  the  room  occupied  by  the  patient.  It 
must  be  confessed  that  many  of  these  circulars  are  not 
very  ^vell  prepared,  exaggerate  very  much  some  of  the 
means  by  wliich  the  disease  is  spread,  pass  lightly  o^er 
others,  and  suggest  many  unnecessary  and  impossible 
things. 

ControJ  of  expectoyat'ion. 

At  one  time  more  importance  was  attached  to  the 
spread  of  tul)erculosis  1)y  the  inhalati(ni  of  the  dust  of 
the  streets  and  public  places  than  is  at  the  present 
time.  As  a  result  of  the  view  that  tuberculosis  is 
chiefly  spread  in  this  way,  various  ordinances  have  been 
adopted  to  ])revent  indiscriminate  expectoration.  The 
first  rule  of  this  kind  was  that  adopted  by  the  Board  of 
Health  of  New  York  City,  May  12,  1896.  By  this  rule 
it  was  forl)idden  to  spit  upon  the  floor  of  the  public 
buildings,  of  railroad  cars  and  ferry-boats.  Rules 
covering  this  sujjject  have  since  been  adopted  l)y  a 
large  numl)er  of  cities  and  towns  and  by  the  State  Board 
of  Health  of  Indiana,  but  have  not  yet  been  incor- 
porated into  statute  laws.  Many  of  the  rules  go  much 
further  than  that  of  New  York,  and  forbid  spitting  in 
omnibusses,  hacks,  carriages,  vehicles,  steam-cars,  or 
any  pul)lic   conveyance,  also  in  public  halls, 'assembly 


OF    TUBERCULOSIS.  li 

rooms,  shops,  stores,  halls,  i-ailway  stations,  churciies, 
sehoolhouses,  and  other  })Lil)lie  places.  Some  of  the 
rules  go  further  still,  and  forhid  the  spitting  upon  the 
sidewalk,  as  in  Cincinnati,  Cambridge,  Colorado 
Springs,  l^rookline.  Providence,  Springfield,  and 
Rochester.  The  following  is  the  rule  in  Cambridge, 
and  perhaps  is  as  explicit  as  any  : 

Cambridoe  ;  Rules  of  the  Board  of  Health,  April  12,  1S99  : 

The  Board  of  Health  hereby  adjudoes  that  spitting  upon  the 
floor,  platform,  or  any  other  part  of  a  public  conveyance  ;  upon 
the  floor,  steps,  or  stairs  of  any  public  building,  hall,  church,  rail- 
way station,  or  sho]> :  upon  the  sidewalk  of  any  street,  court  or 
passageway;  or  ui)on  the  patlnvay  of  any  park,  square,  or  com- 
mon is  a  nuisance,  source  of  Hlth  and  cause  of  sickness,  and  pro- 
hibits spitting  in  any  and  all  such  places. 

Many  of  the  rules  require  tliat  copies  of  the  rule 
shall  be  conspicuously  hung  in  public  conveyances  and 
other  public  places.  Most  of  the  transportation  com- 
panies are  very  ready  to  do  this,  and  have  welcomed 
the  law,  and  have  tried  to  enforce  it. 

Cases  have  Ijeen  brought  for  violation  of  these  rules, 
and  it  is  said  that  the  courts  have  sustained  them.  It 
requires  a  good  deal  of  effort,  however,  on  the  part  of 
the  police,  to  secure  any  permanency  in  this  reform. 
It  is,  perhaps,  questionable  whether  rules  of  this  kind 
can  be  enac^ted  as  necessary  for  the  preservation  of 
])ublic  health,  but,  fortunately,  it  is  not  necessary  to 
prove  the  exact  i-(jle  played  by  promiscuous  spitting  in 
the  production  of  tuberculosis  to  enact  such  legislation. 
Promiscuous  spitting  is  a  nuisance  and  may  be  sup- 
pressed on  that  score  alone,  thus  enabling  us  to  try  a 
very  practical  experiment  as  to  the  importance  of  one 
alleged  means  of  spreading  tuberculosis. 


28  THE    STATE    CONTROL 

The  surest  way  to  prevent  expectoration  in  ])laces 
where  it  may  be  dangerous  is  to  keep  consumptives 
out  of  such  phices.  It  is  dou))tless  for  this  reason  that 
Pennsylvania  has  passed  a  hiw  forbidding  tlie  employ- 
ment ])y  bakers  of  persons  having  consumption,  and 
the  sanitary  code  of  Yonkers  makes  it  a  misdemeanor 
for  leakers  or  market-men  to  pursue  their  occupation  if 
they  have  this  disease. 

Very  little  lias  Ijeen  done  Ijy  any  municipality  to 
control  expectoration  by  regulating  the  conduct  of  the 
individual.  In  New  York  City,  wdien  a  case  of  con- 
sumption is  reported  to  the  board  of  health,  unless  the 
attendant  physician  recjuests  otherwise,  an  inspector  is 
sent  to  the  home  of  the  patient  and  gives  verljal  direc- 
tions how  to  dispose  of  tlie  sputum  without  danger  to 
others.  Subsequent  visits  are  made  to  see  that  these 
directions  are  carried  out,  and  it  is  claimed  that  they 
are  in  about  one-half  of  the  cases.  Doubtless,  all  over 
the  land,  educated  physicians  in  private  practice  and 
in  charge  of  institutions,  have  done  much  to  teach 
patients  in  regard  to  this  matter,  and  prol)a])ly  have 
accomplished  far  more  than  have  the  health  officials. 

Disinfection. 

Experiments  have  shown  that  it  is  ([uite  possible 
that  the  apartment  occupied  by  a  consumptive  patient 
may  become  infected  with  the  germs  of  the  disease. 
Scrapings  have  Ijeen  taken  from  the  Avails  and  furni- 
ture of  such  apartments,  and  have  Ijeen  found  to 
contain  bacilli.  There  is  not,  however,  much  clinical 
eA'idence  that  such  apartments  may  be  the  cause  of 
spreading  the  disease.  The  investigations  of  Flick,  in 
Philadelphia,  and  of  the  board  of  health  in  New  York 


OF    TUBERCULOSIS.  29 

City,  show  that  certain  houses  appear  to  be  the  homes 
of  tuberculosis.  Certain  houses  have  had  cases  in 
them  for  a  long  series  of  years.  A  minority  of  the 
houses  furnish  a  majority  of  the  cases.  There  are  few 
cases  on  record,  however,  where  a  tubercular  family 
has  removed  from  a  house  and  a  non-tubercular  family 
entered  it  and  Jjecome  infected.  A  case  of  this  kind 
has  recently  been  reported  in  the  Indletin  of  the  Ohio 
State  Board  of  Health.  But  such  cases  are  not  more 
numerous  than  could  reasonably  he  explained  as  coin- 
cidences. 

Still,  it  nnist  be  admitted  that  there  is  some  chance 
of  the  disease  Ijeing  spread  in  this  manner,  so  that  it  is 
advisable  to  disinfect  premises  that  have  been  occupied 
by  consumptives  before  they  are  occupied  by  others. 
This  is  commonly  done  by  municipal  boards  of  health, 
when  requested  ))y  the  family,  and  such  requests  are 
becoming  quite  common.  Doubtless,  alsO,  many  per- 
sons thoroughly  cleanse  the  premises,  practically  disin- 
fecting them,  without  calling  upon  the  health  otiicers. 
A  few  cities,  notably  New  York,  require  the  disinfec- 
tion of  such  premises  ;  but  the  method  prescribed  is 
cleansing,  rathei-  than  disinfection.  It  is  required  that 
all  walls  and  woodwork  shall  be  washed  with  washing 
soda,  one-half  pound  to  a  pailful  of  hot  water,  and  then 
the  room  is  repapered,  whitewashed  or  kalsomined. 
Occasionally  goods  are  taken  away  and  steamed. 

HospltaU. 

It  is  considered  that  isolation  hospitals  are  a  neces- 
sity for  the  control  of  communicable  diseases.  If  they 
are  needed  in  scarlet  fever,  diphtheria  and  small-pox, 
thev  are  needed  still  more  in  tuberculosis.     Jn  tuber- 


30  THE    .STATE    CONTROL 

ciilosis,  far  more  than  in  any  otlior  disease,  does  the 
welfare  of  the  })atient  depend  npon  hospital  treatment. 
By  going  to  a  hospital,  not  only  does  a  patient  avoid 
all  danger  of  giving  the  disease  to  others,  but  he 
stands  a  nnich  Ijetter  chance  of  getting  well.  There 
are  not  many  hospitals  for  consimiptives  in  the  United 
States,  and  some  of  these  are  designed  more  as  homes 
of  refuge  for  the  inciu-al)le  poor  than  as  true  sanatoria. 
In  Germany  the  use  of  hospitals  for  the  cure  of  con- 
sumptives has  been  known  for  a  long  time.  There  are 
many  such  hospitals,  and  many  patients  are  cured  in 
them.  Knopf  says  that  cures  can  be  obtained  in  from 
25  to  50  per  cent,  of  the  ca^es.  Of  5,032  patients  at 
Goerbersdorf,  in  Germany,  from  1876  to  1886,  11  per 
cent,  were  reported  as  cured,  and  15  per  cent,  as 
almost  cured.  Of  1,390  received  during  the  first 
stage  of  the  disease,  27  per  cent,  were  cured,  and  31 
per  cent,  almost  cured.  The  other  German  sanatoria 
report  cures  of  from  14  to  27  })er  cent.  Several  French 
sanatoria  report  cures  of  from  21  to  50  per  cent.  The 
Loomis  sanitarium  in  New  York  reports  25  per  cent,  of 
cures  and  50  per  cent,  of  ameliorations.  The  Saranac 
sanitarium  reports  20  to  25  per  cent,  of  cures.  At 
Chestnut  Hill,  Philadelphia,  where  patients  in  all  stages 
are  received,  there  are  8  per  cent,  of  cures  and  11  per 
cent,  of  ameliorations.  Perhaps  the  most  striking 
proof  of  the  ^-alue  of  hospital  treatment  is  shown  hy 
the  action  of  the  st?ite-aided  insurance  companies  of 
Germany.  These  companies  Hnd  it  for  their  advan- 
tage to  send  their  policy  holders  who  become  phthisi- 
cal, to  sanatoria,  and  to  pay  their  board  while  there. 
During  1898,  Ijetween  three  and  four  million  marks 
were  expended  for  that  purpose.      It  has  Ijeen  shown 


OF    TrCERCULOSIS.  31 

that  it  is  not  necessary  to  go  into  deejj  forests  or  high 
mountain  regions  to  secure  a  good  location  for  a  con- 
sumptive hospital.  Dry  and  somewhat  isolated  situa- 
tions can  be  found,  suital)le  for  these  hospitals,  within 
a  few  hours'  journey  of  nearly  all  our  cities.  Consid- 
erable difticulty  has.  at  times.  l)een  found  in  seeming 
a  site  for  such  hospitals,  the  people  of  the  locality  tear- 
ing: it  mav  be  the  means  of  introducino-  contao-ion. 
This  fear  is  unfounded.  The  care  which  is  exercised 
in  hospitals  to  prevent  the  spread  of  contagion  is 
etfectual.  It  is  shown  that  at  Goerbersdorf  and  Fal- 
kenstein,  the  death  rate  from  phthisis  has  diminished 
from  18  to  11  per  cent,  since  the  sanitoria  were  estab- 
lished. 

Hospitals  not  only  help  to  cure  a  patient  and  keep 
him  from  infecting  others,  but  they  teach  him  habits 
of  care  in  regard  to  the  disposal  of  spntmn,  and  in 
•other  ways  instruct  him  in  the  principles  of  hygiene, 
so  that  when  he  leaves  the  hospital  he  is  much  more 
likely  than  liefore  to  lead  a  healthful  life  and  to  avoid 
infecting  others. 

The  cost  of  treatment  in  hospitals  designed  for  the 
care  of  consumptives  is  not  far  from  the  cost  in  gen- 
eral hospitals.  The  cost  in  the  German  hospitals  is  6(1 
to  80  cents  per  day;  the  cost  in  St.  Joseph's  Hospital, 
New  York  Ci^y,  is  50  cents  ;  and  of  the  Chestnut  Hill 
Hospital  in  Phihxdelphia,  40  cents.  These  hospitals, 
however,  do  not  offer  the  best  facilities.  The  cost  at 
Saranac  Lake  is  from  $1  to  |1.2o  ;  at  the  Loomis  San- 
itarium, $1.43  ;  at  the  Cincinnati  Hospital,  about 
.$1.25.  The  exact  figures  for  the  hospital  in  Massa- 
chusetts are  not  given,  but  are  apparently  considerably 
greater.     Knopf  says   it   is   more   economical  for   the 


32  THE    STATE    CONTROL 

municipality  to  care  for  its  phthisical  poor  in  special 
sanitaria  than  it  is  in  general  hospitals.  The  initial 
cost  may  be  somewhat  greater,  but  the  length  of  stay 
is  pretty  certain  to  1)e  less,  and,  in  the  aggregate, 
many  years  of  useful  life  will  be  preserved  to  the 
community. 

Considering  tlie  advantages  wliich  are  secured  hy 
hospital  treatment,  it  is  rather  remarkaljle  that  in  this 
country  so  little  has  been  done  l)y  the  state  to  furnish 
it.  The  first  and  only  municipal  liospital  for  the  care 
of  consumption,  with  which  the  writer  is  ac([uainted, 
was  that  at  Cincinnati.  This  is  a  substantial  brick 
Ijuilding  in  the  suburbs,  jjuilt  for  a,  smallpox  hospital, 
but  devoted  to  the  care  of  consumptives  since  July  8, 
1897.  The  hospital  and  other  buildings,  exclusive  of 
land,  cost  about  |rSO,000. 

During  the  first  two  years  that  the  building  was 
occuj)ied,  330  patients  were  treated.  The  visiting 
physician.  Doctor  Lyle,  reports  some  cures  and  many 
improvements,  but  he  has  not  been  able  to  follow  the 
cases  very  carefully  after  their  discharge.  This  hos- 
pital, however,  is  not  intended  so  much  as  a  curatixe 
institution  as  an  isolation  hospital  to  which  patients 
may  go  instead  of  entering  the  general  hospitals  of  the 
city. 

Massachusetts  has  set  the  example  for  the  establish- 
ment of  State  hospitals.  The  Massachusetts  Hospital 
is  at  Rutland,  in  that  State,  and  was  opened  for  the 
reception  of  patients  on  Oct.  1,  1898.  It  is  intended 
to  accommodate  200  patients,  and  cost  over  $150,000. 
It  is  intended  for  patients  in  the  early  stages  of  the 
disease.  There  is  a  uniform  charge  made  of  50  cents 
per  day,  but  poor  patients  may  l)e  admitted  without 


OF    TUBERCULOSIS.  33 

charge  on  application  of  the  poor  department  of  the 
town  to  which  they  belong.  Of  conrse,  this  board 
does  not  begin  to  pay  the  running  expenses,  and  these 
are  met  by  State  appropriation. 

Control  of  Milk  Supply. 

It  is,  of  course,  useless  to  attempt  to  secure  a  milk 
supply  which  shall  be  free  from  tuberculous  taint, 
except  by  inspection  and  control  of  the  dairies  from 
which  the  milk  is  derived.  As  yet,  not  very  much 
has  been  done  along  this  line,  in  the  United  States. 
In  New  Jersey  and  Wisconsin  the  laws  permit  of  the 
inspection  and  licensing  of  dairies.  In  Minnesota  a 
somewhat  recent  law  confers  upon  cities  the  authority 
to  license  milk  producers,  and  inspect  and  test  dairy 
cows.  This  law  has  been  tested  and  its  validity 
upheld  by  the  Supreme  Court.  Notwithstanding  the 
dearth  of  specific  legislative  authority,  a  considerable 
number  of  cities  have  taken  more   or  less   enero-etic 

o 

action,  looking  to  the  supervision  of  the  sources  of 
their  milk  supply.  In  some,  the  action  taken  is 
merely  one  of  inspection,  advice  and  publicity ;  in 
others,  control  is  exercised  over  dairies  within  tlie 
jurisdiction  of  the  municipality.  In  others,  the  at- 
tempt is  made  to  control  all  the  sources  of  milk  supply 
of  the  city.^ 

It  is  necessary,  first,  to  obtain  a  knowledge  of  all 
the  dairy  cattle  supj^lying  the  city.  To  accomplish 
this,  every  dealer  must  be  licensed  and  must  keep  the 
authorities  informed  of  the  location  of  every  herd 
from  which  he  obtains  milk.  This  method  is  followed 
in  New  York,  Minneapolis,  St.  Paul,  the  District  of 


34  THE    STATE    CONTROL 

Columbia,  St.  Louis,  Buftalo,  Lynn,  Nashua,  Portland, 
and  other  cities. 

The  second  step  is  to  provide  for  an  inspection  of 
the  herds  and  dairies  from  which  the  milk  is  derived. 
Sometimes  this  inspection  is  confined  to  the  limits  of 
the  city,  as  it  is  in  New  York,  Baltimore,  Cincinnati, 
and  the  District  of  Columbia.  Of  course,  such  local 
inspection  cannot  accomplish  much.  Every  herd  sup- 
plying the  city  should  ])e  controlled.  Among  cities 
which  have  attempted  to  inspect  every  herd  supplying 
the  city  may  be  mentioned  Portland,  Lynn,  Nashua? 
Rochester,  the  District  of  Columbia,  Minneapolis,  St. 
Paul,  St.  Louis  and  San  Francisco. 

Lastly,  it  is  necessary  to  test  with  tuljerculin  ever}^ 
animal  from  which  the  municipal  supply  is  derived. 
By  licensing  dealers,  by  registering  jDroducers,  by  in- 
specting their  herds,  by  testing  the  cattle  witli  tuber- 
culin, and  condemning  all  infected  animals,  hy  tagging 
the  animals  so  that  they  may  be  identified,  and  by  re- 
inspecting,  at  intervals,  the  milk  supply  may  be  kept 
free  from  tuberculosis.  This  method  has,  at  present, 
been  successfully  adopted  only  in  Portland  and  Westr 
brook,  Me. ;  in  Lynn,  in  Minneapolis,  and  St.  Paul. 
Such  drastic  methods  are  sure  to  meet  with  great 
opposition,  and  permissive  legislation  is  difficult  to 
obtain.  The  attempt  was  made  in  the  District  of  Col- 
umbia, and  San  Francisco,  but  Avas  a  failure.  In 
Massachusetts,  also,  the  authority  was  sought  by  which 
local  boards  of  health  could,  in  this  manner,  control 
the  milk  supply,  but  it  was  successfully  of)posed  by 
the  milk  dealers  and  producers. 

The  attempt  has  been  made  in  New  Orleans,  St. 
Paul,  Indianapolis,  and,  doubtless,  in  other  cities,  to 
improve    the    milk    sup]3ly    by    moral  agencies.     The 


OF    TUBERCULOSIS.  35 

municipal  authorities  offered  to  test  tlie  dairyman's 
herd  and  certify  to  those  which  were  found  healthy. 
Few,  howeyer,  took  adyantage  of  the  offer,  for  they 
did  not  find  that  the  expense  and  trouble  were  com- 
pensated by  increased  custom.  This  method,  howeyer, 
was  successful  in  Indianapolis,  where  nearly  all  the 
dairymen  liaye  yoluntarily  sul)jected  their  animals  to 
inspection.  In  8t.  Paul,  on  the  other  hand,  the  city 
was  obliged  to  resort  to  compulsory  methods.  The 
limited  demand  for  "certified  milk"  shows  that  the 
public  is  hardly  ready  to  ask  for  clean  milk,  or  willing 
to  i^ay  for  it. 

The  Eradication  of  Tuherculosis  in  Cattle. 

If  it  is  true,  as  is  not  improbable  and  as  many  would 
haye  us  belieye,  that  a  large  part,  perhaps  eyen  half, 
of  human  tuberculosis  is  deriyed  from  cattle,  an  impor- 
tant step  in  controlling  the  disease  in  man  is  to  get 
rid  of  it  in  animals.  It  may.  perhaps,  be  admitted 
that  the  eyidence  is  not  strong  enough  to  warrant  our 
taking  the  radical  ste'ps  necessary  to  get  rid  of  tuber- 
culosis, on  account  of  its  danger  to  human  beings.  ])ut 
there  are  other  and  ample  reasons  why  the  State 
^should  seek  to  free  its  herds  from  tuberculosis,  as  it 
has  from  pleuro-pneumonia  and  other  infectious  dis- 
eases. In/this  work,  howeyer,  the  co-operation  of  the 
dairyman  and  farmer  cannot  be  expected,  as  it  maybe 
in  the  acute  diseases.  Tuberculosis  is  a  chronic  aft'ec- 
tion.  The  cattle  owner  can  detect  it  long  before 
death,  make  use  of  the  milk  for  a  considerable  period 
of  time,  and  finally  sell  the  animal  for  slaughter,  at  a 
small  loss,  or  perhaps  no  loss  at  all.  The  trouble  and 
■expense    incurred    in    entirely    freeing    a   herd    from 


36  THE    STATE    CONTROL 

tuberculosis  are  considerable,  and  the  average  man 
who  hesitates  to  incur  a  momentary  loss  for  the  sake  of 
future  gain,  had  rather  take  the  chances  of  losing 
a  little  money  now  and  then  on  a  cow,  than  of  going 
to  the  trouble  of  getting  rid  of  the  disease  altogether. 
Nevertheless,  the  aggregate  loss  from  tuberculosis  is 
enormous,  and  the  State  would  be  justified  in  making 
large  expenditures  to  exterminate  it. 

Various  plans  have  been  suggested  and  tried  for 
getting  rid  of  tuberculosis  in  cattle.  The  most  radical 
measures  were  those  adopted  in  Massachusetts,  where 
the  plan  was  adopted  of  inspecting  every  animal  in 
the  State,  and  killing  and  destroying  all  which  reacted 
with  tulierculiu.  Large  sums  of  money  were  ex- 
pended, great  opposition  was  aroused,  and  the  plan 
had  to  be  abandoned.  A  somewhat  similar,  but  less 
rigorous  method,  was  adopted  in  Belgium,  in  1896, 
but  it  also  has  been  modified.  In  Baden,  herds  from 
which  tuberculous  cattle  are  reported  by  the  meat 
inspectors  are  examined  and  measures  taken  for  the 
suppression  of  the  disease  at  the  expense  of  the  state. 
In  Baden,  as  in  Saxony  and  other  parts  of  Germany, 
a  part  of  tuberculous  meat  is  used  as  food.  In  France, 
also,  the  flesh  of  tuberculous  animals  is  not  always 
condemned,  though  animals  that  are  discovered  to  be 
tuberculous  are  always  killed.  In  Denmark,  the  state 
offers  to  test  herds  for  their  owners,  and  tuberculous 
cattle  are  killed  if  the  disease  is  far  advanced,  and 
their  flesh  is  then  destroyed.  In  the  early  stages  of 
the  disease  the  animals  may  be  kept  in  quarantine,  or 
they  may  be  slaughtered  and  are  largely  used  for 
food ;  Ijut  the  milk  and  cream  of  quarantined  animals 
cannot  be  used  without  pasteurization.  A  similar 
plan  has  been  adopted  in  Norway. 


OF    TUBEECULOSIS.  37 

It  is  of  specital  interest  to  us  to  know  what  is  Ijeing 
done  in  the  United  States. 

The  importation  of  tuljerculons  cattle  into  the 
United  States  is  guarded  against  by  the  inspectors  of 
the  Bureau  of  Animal  Industry.  While  this  bureau 
might  under  the  laws  attempt  to  prevent  the  passage 
of  tuberculosis  from  one  state  to  another,  it  has  not 
yet  had  the  means  for  doing  so.  This  is  at.  present 
controlled  by  the  states,  and  eighteen  of  them  have 
laws  respecting  it,  among  which  are  Maine,  New 
Hampshire.  Vermont,  Massachusetts,  Rhode  Island, 
New  Jersey,  Pennsylvania,  Iowa,  Montana,  and  Texas. 
A  common  form  of  the  law  is  that  requiring  that  no 
animal  shall  l)e  imported  without  a  certificate  that  it 
has  been  inspected  and  tested  with  negative  results. 
In  Texas  cattle  must  not  be  imported  for  breeding  or 
dairy  purposes,  and  an  exception  is  made  in  favor 
of  animals  certified  to  as  natives  of  Colorado  or  Ne- 
Ijraska.  In  New  Hampshire  animals  may  be  brought 
in  for  pasturage  only,  without  the  tuberculin  test, 
provided  they  are  sound  on  physical  examination.  In 
Connecticut,  when  any  one  imports  cattle  from  an 
adjoining  State  he  must,  within  six  days,  notify  the 
commissioner  on  domestic  animals. 

Very  little  work  has  l^een  done  in  eradicating  l^ovine 
tuberculosis  Ijy  municipal  health  officers  except  in 
connection  with  the  protection  of  the  milk  supply. 
Nearly  all  the  active  work,  except  in  a  few  cities  as 
New  York.  Minneapolis,  St.  Paul,  Indianapolis,  Roch- 
ester and  Lynn,  has  been  done  by  state  boards.  Some 
of  this  work  is  done  by  l^oards  of  cattle  commissioners 
and  some  by  state  boards  of  health.  Much  of  the 
following  summary  is  taken  from  the  seventh  annual 
report  of  the  state  veterinarian  of  Maryland. 


38  THE    STATE    CONTROL 

3IassachHsetts.  Under  Chapter  491,  acts  of  1894, 
some  465  inspectors  were  apjDointed,  whose  duty  it 
was  to  inspect  cattle  and  stables,  and  report  the  occur- 
rence of  any  contagious  disease.  All  cattle  visibly 
affected  with  tuberculosis  were  killed  and  paid  for, 
while  many  w^ere  tested  at  State  exj)ense  at  a  cost  of 
$240,737.84.  This  does  not  include  the  cost  of  test- 
ing many  more  cattle,  which  was  made  at  the  expense 
of  individual  owners. 

Condemned  cattle  were  paid  for  upon  written  applica- 
tion for  the  test  to  be  applied,  and  upon  the  provision 
to  thoroughly  disinfect  their  premises,  and  to  introduce 
none  but  cattle  tested  (at  owner's  expense)  in  future. 
This  led  to  an  order  that  cattle  to  be  paid  for  must  be 
tested  Ijy  the  cattle  commissioners  or  their  authorized 
agent.  The  large  amount  of  money  spent  and  the 
numl:>er  of  animals  destroyed  caused  great  opposition 
and  resulted  in  a  change  of  policy.  It  is  now  ref[uired 
by  law  that  each  town  and  city  shall  appoint  an  in- 
spector who  will  act  in  conjunction  with  the  state  board. 

This  work  may  be  considered  under  three  heads : 

1.  The  supervision  of  the  traffic  in  live  cattle 
brought  into  the  State. 

2.  A  general  inspection,  the  examination  of  cattle 
quarantined  as  diseased  by  the  local  inspectors  in  the 
various  cities  and  towns,  and  the  payment  for  those 
found  to  be  infected  with  tuberculosis. 

3.  Testing  entire  herds  for  the  purpose  of  perma- 
nently eradicating  tuberculosis  from  the  premises. 

In  1899,  $75,000  was  appropriated  and  only|50,000 
was  to  be  asked  for  the  next  }' ear  ;  785  tuberculous 
animals  were  killed,  for  which  $17,277.69  was  paid  ; 
565  animals  were  tested  for  owners  who  Avere  trying 
to  free  their  herds,  and  of  these  63  were  condemned. 


OF    TUBERCULOSIS.  39 

Maine.  Maine  was  the  first  of  the  New  England 
States  to  adopt  the  system  of  placing  quarantine  on 
the  admission  of  out-of-state  cattle.  The  law  was 
first  enforced  in  1802  against  Massachusetts,  because 
of  the  large  per  cent  of  Massachusetts  cattle  that  were 
found  diseased.  Later  it  was  placed  on  all  out-of-state 
territory,  except  on  such  animals  as  were  provided 
with  certificates  of  the  tuberculin  test.  The  authori- 
ties in  Maine  test  lierds  only  on  the  voluntary  applica- 
tion of  the  owner.  The  owner  to  receive  one-half  the 
value,  as  determined  on  the  basis  of  health  before 
infection,  the  limit  of  compensation  being  $100  for 
pedigreed  animals  and  |50  for  others.  The  commis- 
sion have  power  to  investigate  as  to  the  existence  of 
disease  and  to  condemn  and  destroy  such  as  show 
physical  evidence  of  disease.  During  the  year  1898, 
415  head  of  -cattle  were  destroyed  at  an  appraisal  of 
$18,122. 

Vermont.  Vermont,  with  its  small  percentage  of 
diseased  animals,  has  probably  been  more  successful 
than  any  other  State  in  its  attempts  to  control  tuber- 
culosis. Since  Feb.  1,  1897,  60,000  have  been  tested, 
and  2,360  have  been  found  diseased  and  killed,  a 
percentage  of  disease  of  nearly  four  per  cent.  In 
Vermont  i^o  animals  are  tested  unless  the  owners 
allow  the  entire  herd  to  be  tested,  and  thereafter  every 
animal  admitted  to  the  herd  must  be  tested  and  the 
stables  thoroughly  disinfected.  The  commission  test 
only  where  application  is  made  by  the  owner.  In 
their  annual  report  a  list  of  seventy-eight  retested 
herds  is  given,  in  which  tuberculous  animals  were 
found.  Twenty-three  herds  were  found  free  on  the 
second  test,  and  twenty-three  had  only  one  case  each 
on  the  second  test.     Eight  of  the  remaining  herds  that 


40  THE    STATE    COXTHOL 

were  found  diseased  on  the  second  test  were  free  on 
the  tliird  test.  The  report  states  that  "  the  proper  dis- 
infection is  a  more  diffienlt  matter  tlian  is  the  discovery 
of  the  diseased  animal."' 

The  commissioners  have  found  that  cattle  Ijuyers 
from  States  where  no  ({narantine  was  enforced  have 
purchased  many  suspected  animals  at  a  price  a  little 
less  than  would  have  been  paid  if  not  suspected. 

New  Hampshire.  Diseased  animals  are  reported  to 
the  commission  through  the  selectmen,  and  are  released 
or  condemned  on  physical  examination. 

When  the  owner  applies  for  inspection  of  his  herd, 
and  where  there  is  reason  to  believe  the  disease  exists, 
the  board  may  treat  the  entire  herd,  the  owner  receiv- 
ing half  compensation.  In  1808,225  herds  were  tested 
and  148  animals  killed  for  which  $2,894  was  paid. 

Hhode  Island.  Rhode  Island  has  a  commissioner  in 
each  county,  appointed  by  the  l)oard  of  agriculture, 
whose  duty  it  is  to  inquire  into  the  condition  of  any 
animal  in  their  county  whenever  there  is  any  reason  to 
suspect  tuberculosis.  When  any  animal  is  thought  to 
be  tuberculous  by  a  commissioner,  he  shall  immediatel}^ 
quarantine  and  examine.  In  1 898,  49G  animals  were 
killed  for  which  $9,014.50  was  paid. 

JVeiD  Yorli.  In  New  York  state,  tuberculosis  in  cat- 
tle is  handled  l)y  a  tuberculosis  committee  of  the  state 
board  of  health.  No  appropriation  has  been  made  by 
the  legislature  for  the  use  of  this  committee  and  no 
cattle  have  been  ordered  killed,  except  where  the  owners 
have  waived  all  right  to  compensation.  The  commit- 
tee, however,  have  received  many  requests  from  owners 
asking  to  have  their  herds  tested ;  and  also  test  the 
animals  belonging  to  public  institutions. 


OF    TUBERCULOSIS.  41 

JVew  Jersey.  New  Jersey  lias  a  commission  of  seven 
members.  The  commission,  on  application  from  the 
owner,  the  state  board  of  health  or  the  state  dairv  com- 
mission, will  make  an  examinatien  of  suspected  herds, 
the  reacting  animals  to  be  condemned  and  killed. 
They  are  appraised  at  their  market  value,  not  exceed- 
ing forty  dollars,  the  owner  receiving  compensation  at 
the  rate  of  three-fourths  of  their  valuation.  In  1898 
there  were  tested  1,438  cows,  of  which  245  were  con- 
demned. The  cost  of  inspection  was  $1,179,  and  the 
amount  paid  for  the  cows  was  $5,098.20. 

Pennsylvania.  It  has  been  the  practice  in  Pennsyl- 
vania to  test  herds  only  on  the  application  of  the  owner, 
and  then  only  where  the  disease  was  suspected  to  exist. 
The  application  is  made  on  a  printed  form,  and  in  mak- 
ing the  application  the  owner  promises  to  observe  every 
direction  recommended  that  tends  to  the  purification 
of  his  premises.  If  he  has  to  tear  down  half  his  Ijarn, 
or  cut  windows  through  his  stables,  or  put  in  new 
floors,  he  agrees  to  do  that  before  the  examination  is 
made,  and  he  agrees  also  to  procure  his  animals  for 
restocking  from  as  healthy  a  source  as  possible.  It 
has  been  impossil)le,  however,  to  comply  with  all  the 
recjuests  sent  in,  and.  as  far  as  possible,  the  worst  herds 
have  been  picked  out  for  testing.  Reacting  animals 
are  all  condemned  and  compensation  given  the  owner. 

At  the  time  of  pul^lication  of  the  last  annual  report 
the  average  appraisement  for  cattle  condemned  was 
twenty-four  dollars  and  fifty  cents.  Since  the  begin- 
ning of  the  last  fiscal  year  the  total  payments  for  tuljer- 
culous  cattle  to  date  (January  1,  1898,)  amount  to 
$57,191.16  for  2,510  animals,  an  average  of  $22.78 
per  head. 


42  THE    STATE    CONTROL 

In  Pennsylvania  the  number  of  cattle  tested  up  to 
the  1st  of  June,  1897,  was  0,108  ;  the  number  con- 
demned as  tuberculous  was  1,839,  a  percentage  of  20.39. 
Since  the  1st  of  June,  4,887  cattle  have  been  tested ; 
of  these  671  were  found  to  be  tuberculous  and  were 
killed ;  a  percentage  of  13.73.  All  parts  of  the  state 
are  represented  among  these  herds,  as  only  herds  sus- 
pected as  diseased  are  tested.  The  state  officials  be- 
lieve that  many  of  the  w^orst  herds  have  been  discov- 
ered, and  that  the  percentage  of  tuberculosis  among 
cattle  at  large  is  being  steadily  and  rapidly  re- 
duced. 

lU'mois.  The  live  stock  commission  has  been  con- 
ducting tests  on  herds  where  the  OAvners  appl}^  for  it. 
All  animals  are  slaughtered  w^ithout  compensation,  the 
owners  having  whatever  there  may  be  from  the  sale  of 
the  hide  and  carcass ;  where  the  disease  is  slight  the 
beef  may  be  sold,  if  fit,  for  food. 

During  the  year  1897,  36  herds  were  tested,  includ- 
ing 851  animals;  of  these  77  were  found  diseased,  or 
about  9  per  cent.  (This  percentage  includes  a  herd  of 
251  that  had  previously  been  tested.)  Of  the  77  dis- 
eased animals,  41  carcasses  were  condemned  and  36 
passed  as  fit  for  food. 

During  the  year  the  board  has  made  tuberculin  tests 
on  all  dairy  herds  for  which  applications  w^ere  made. 
There  were  fewer  tests  made  in  1898  than  during  the 
previous  year,  not  because  the  disease  was  any  less 
prevalent  among  the  untested  herds  of  the  state,  but 
simply  because  a  less  number  of  owners  of  herds  ap- 
peared to  be  willing  to  bear  all  the  loss  to  be  sustained 
thi'ough  the  members  of  their  herds  that  would  respond 
to  the  test. 


OF    TUBERCULOSIS.  43 

Mlchifjan.  Cattle  found  to  be  tuberciiloiis  are  quar- 
antined and  killed.  The  laAvdoes  not  provide  compen- 
sation, however,  and,  as  a  result,  the  commission  has 
met  with  a  good  deal  of  opposition.  The  commission 
has  followed  the  plan  of  inspecting  animals  brought  to 
their  attention  as  suspicious,  and  killing  such  as  reacts 
without  compensation. 

During  181J7  and  1808  the  commission  has  applied 
the  tul)erculin  test  to  nearly  1,000  head  of  cattle,  a 
goodly  proportion  being  milch  cows.  In  fact,  a  larger 
number  of  cattle  have  been  tested  for  tuberculosis  dur- 
ing the  last  two  years  than  had  previously  been  tested 
since  the  tuljerculin  test  was  adopted  by  the  commis- 
sion. 

The  tuberculin  test  is  apphed  only  when  suspicion  is 
directed  toward,  or  complaint  made  of,  either  a  single 
animal  or  an  entire  herd.  The  records  of  tests  made 
show  but  a  small  per  cent,  of  infected  animals,  and 
when  it  is  considered  that  only  suspicious  herds  are 
tested,  it  is  felt  to  be  a- safe  estimate  that  less  than  two 
per  cent,  of  the  cattle  in  Michigan  are  affected  with 
tuberculosis. 

Minnesota.  All  cattle  which  show  symptoms  of 
tuberculosis  must  be  quarantined  at  once  and  the 
entire  herd  tested  with  tuberculin.  When  cattle  have 
once  reacted  the  owner  has  his  option  of  having  them 
killed  or  continued  in  quarantine  for  a  j^eriod  not  to 
exceed  three  months,  when  they  are  again  tested.  If 
they  react  on  the  second  test,  they  must  be  killed  within 
one  month.  The  owner  has  no  compensation  for  cattle 
killed,  but  he  is  allowed  to  have  them  killed  under 
inspection,  and,  if  they  pass,  he  can  dispose  of  the 
flesh  like  any  other  beef.     In  1898,  2,975  cows  mostly 


44  THE    STATE    CONTROL 

fui'uisliiiig  milk  to  St.  Paul  were  tested  and  G.37  per 
cent,  were  condemned. 

Wiscoitsij/.  The  state  l)oard  of  health  are  applying 
the  tubercidin  test  to  infected  herds  reported,  as  far  as 
their  means  Avill  allow  and  condemning  the  animals 
that  react  to  the  test,  the  state  paying  two-thirds  of 
the  appraised  value. 

It  has  not  seemed  necessary  in  this  discussion  to  con- 
sider the  value  of  the  tuberculin  test  any  more  than 
the  causative  relation  of  the  tuljercle  bacillus  to  the 
disease.  All  competent  persons  seem  agreed  that  in 
tuberculin  we  have  the  Ijest  means  possijjle  for  making 
a  diagnosis  of  this  disease.  It  is  not  infallible,  hut  per- 
mits a  very  much  surer  diagnosis  than  can  be  obtained 
by  any  other  means.  Without  it,  the  eradication  of 
tuberculosis  would  be  much  more  difficult  and  expen- 
sive than  with  it. 

With  tuberculin  the  recognition  of  the  disease  is  the 
most  certain  part  of  the  work.  Perhaps  the  most  diffi- 
cult part  is  the  disinfection  of  infected  premises.  The 
following  directions  which  the  Massachusetts  Board  of 
Cattle  Commissioners  insist  on  being  carried  out  on  all 
premises  that  they  attempt  to  free  from  the  disease  are 
perhaps  as  good  as  any  : 

REGULATIONS  OF  MASSACHUSETTS  liOARD  OF  CATTLE 
COMMISSIONERS  FOR  CLEANSING  AND  DISINFECTING 
BARNS. 


lliese   Must   he    (.'oiiqilied    With    by  Ov:ners  of  Cattle,    U'/ilrh  the  State 

Payn  For. 


In  attempting  to  get  rid  of  tuberculosis  in  a  herd  of  cattle,  it 
should  be  remembered  that  not  oul}"  is  it  necessary  that  all  the 
diseased  animals  be  picked  out  and  either  isolated  or  destroyed- 


OF    TUBERCULOSIS.  45 

but  that  no  new  animals  should  be  introduced  unless  they  have 
been  tested  and  are  known  to  be  free  from  disease. 

The  barns  should  also  imdergo  a  thorough  renovation  and  be 
properly  cleansed  and  disinfected  before  they  are  again  occupied. 

In  renovating  or  remodelling  barns  the  great  imjiortance  of 
sunlight,  thorough  ventilation  and  good  drainage  should  always 
be  borne  in  mind. 

Disinfection  of  the  barns  is  always  necessary  to  destroy  any 
infectious  material  that  may  have  been  left  after  the  removal  of 
diseased  cattle.  The  best  disinfectant  we  know  is  sunlight. 
Germs  of  disease  will  live  but  a  short  time  when  exposed  to  the 
direct  rays  of  the  sun,  and  for  this  reason,  if  for  no  other,  a 
southerly  exposure  and  plenty  of  windows  in  the  barn  are  to  be 
desired. 

In  proceeding  to  disinfect  a  barn  the  first,  and  perhaps  the 
most  important  step  to  be  taken  is  to  collect  all  rubbish,  have  the 
walls,  ceilings  and  floors  thoroughly  swept  and  cleansed  of  all 
litter,  dust,  cobwebs,  and  the  like.  The  floors,  mangers,  feeding- 
troughs  and  stanchions  should  be  carefully  scraped  and  cleaned, 
special  care  being  taken  with  the  corners,  and  all  of  the  rubbish 
xjollected  and  burnsd. 

All  odds  and  ends  of  boards  and  old  and  broken  mangers  and 
partitions  should  also  be  removed  and  burned,  and  when  occa- 
sion requires  it,  new  plank  floors  should  be  laid  in  place  of  old 
ones. 

After  cleaning  thoroughlj^  with  hoe  and  broom,  and  hose  if 
running  Avater  is  convenient,  and  if  the  barn  contains  a  boiler  Avith 
scalding  water,  or  live  steam,  applied  with  a  hose,  or  failing  that, 
with  boiling  water  and  soft  soap  or  Avashing  soda.  A  solution  of 
bichloride  of  mercury  (corrosive  sublimate),  1  to  1,000  parts  of 
Avater,  should  be  applied  Avith  a  AvhiteAvash  brush  and  poured  over 
the  floors.  (CorrosiA-e  sublimate  should  be  used  in  Avooden  ves- 
sels, as  it  corrodes  metal  ones.) 

After  applying  the  corrosive  sublimate,  the  ceilings,  Avails,  par- 
titions, mangers,  etc.,  should  again  be  washed  and  gone  over  Avith 
warm  freshly  made  white Avash ;  a  half  pound  of  chloride  of  lime 
to  the  gallon  of  AvhiteAvash  is  an  addition  that  may  make  it  more 
effective.  Fumigating  with  sulphur  or  chlorine  gas  is  not  of  any 
great  value  in  ordinary  stables. 


46  THE    STATE    CONTROL 

In  using  corrosive  sublimate  it  must  he  borne  in  mind  that  it 
is  a  dangerous  poison,  and  mangers  and  partitions  should  be  care- 
fully Avashed  after  applj'ing  this  mixture,  and  then  again  scalded 
or  whitewashed. 

If  at  a  season  of  the  year  when  the  animals  can  be  turned  out, 
the  stables  should  l)e  left  vacant  for  some  time  with  doors  and 
windows  open. 

Six  months  after  the  first  test  the  herd  should  again  be  tested 
and  undergo  a  careful  physical  examination,  so  as  to  be  certain 
that  no  diseased  animals  have  been  overlooked,  and  the  barns 
should  again  be  thoroughly  disinfected. 

Great  care  also  should  be  taken  that  all  animals  have  been 
tested  before  their  introduction  to  the  herd. 

THE  DECREASE  OF  TUBERCULOSIS. 

Over  most  parts  of  Western  Europe,  Great  Britain 
and  the  United  States,  there  has,  for  half  a  centiuy, 
been  a  marked  decrease  in  the  number  of  deaths  due 
to  tubercuhxr  diseases,  and  particuhxrly  in  deaths  from 
consumption.  The  figures,  of  coin^se,  vary  somewhat 
in  different  localities,  but  the  fact  of  marked  decline  is 
illustrated  by  almost  all  registration  rejDorts  which 
cover  a  considerable  number  of  years.  It  seems  liardlj^ 
necessary  to  present  a  mass  of  statistics  to  demonstrate 
this,  but  it  may  not  be  uninteresting  to  examine  the 
data  from  local  sources  which  are  herewith  presented. 
The  followino;  table  is  from  the  advance  sheets  of  the 
report  on  births,  marriages  and  deaths  in  Providence, 
for  1899.  The  main  fact  of  the  decline  is  shown 
graphically  in  the  succeeding  diagram  : 


OF    TUBERCULOSIS.  47 

Decedents  from  Phthisis,  Forty-four  Years,  1856-1899. 


Parentage. 

Sex. 

1 

S 

American. 

Foreign. 

Males. 

Females. 

ft 

YEARS. 

to 

5 

OS 

c 

ai 

5|  1 

IS 

0  . 

ftp 

1  = 

1 

ftp 

1° 

O 
§ 

a 
o 

1 

1856-60 

1861-65 

1866-70 

1871-75 

1876-80 

1881-85 

1886-90 

1891-95 

1896 

1897 

1898 

1899 

525 

495 

532 

553 

570 

573 

'62^ 

486 

91 

92 

87 

99 

364 
329 
306 
252 

235 
227 
204 

no 

153 
151 
135 
149 

236 

405 

480 

520 

682 

928 

1,177 

1,206 

1,202 

259 

229 

238 

268 

391 

i 
420 

384 

332 

322 

371 

329 

286 

285 

246 

243 

264 

326 

379 
477 
490 
668 
676 
824 
863 
846 
180 
178 
178 
177 

324 
387 
339 
279 
267 
304 
288 
253 
249 
233 
228 
219 

551 
498 
562 
667 
822 
926 
872 
842 
170 
148 
147 
190 

421 
352 
342 
301 
301 
310 
266 
233 
218 
185 
174 
218 

285 

930 

975 

1,052 

1,235 

1,498 

1,750 

1,735 

1,688 

350 

321 

325 

367 

1 

375 
368 
340 
290 
285 
307 
277 
243 
233 
;  208 

;  200 

218 

44  years 

4,632 

1         / 

7,594 

5,831 

285 

6,395 

1 
12, 226 j  285 

48 


THE    STATE    CONTEOL 


Pkovidknce,  R.  I. 
PHTHISIS. 

Deaths  pkh  100,000  Living. 


18.55-1804 
380 


180.5-1874 
317 


187.5-1884 
298 


188.5-1894 
259 


1895-1897 
212 


It  lias  been  claimed  by  many  that  this  diminution  in 
the  death  rate  of  phthisis  is,  to  a  large  extent,  due  to 
the  application  of  the  knowledge  recently  acquired. 

The  writer,  however,  does  not  believe  that  this  is 
the  case.  Certainly,  in  most  places,  as  has  been  shown, 
very  little  has  as  yet  been  accomplished  in  regard  to 
the  purification  of  milk  supplies  or  the  eradication  of 
bovine  disease.  Expectoration  laws  are  not  enforced, 
and  no  more  consumptives  are  cared  for  in  hospitals 
than    formerly.     It  is    true   that  some   few  cases  do, 


OF    TUBERCHTLOSIS.  49 

undouhtedly,  take  rational  measures  to  prevent  infect- 
ing- others.  Physicians  have  been  a)jle  to  teach  a 
minority  of  their  patients  to  do  this.  It  can  scarcely 
be  believed  that  such  very  little  progress  has  produced 
such  marked  results.  The  decrease  in  consumption  in 
the  United  States  has  not  jjeen  due  to  state  control,  for 
the  excellent  reason  that  the  state,  as  yet,  has  not  Ijeen 
able  to  excercise  any  efficient  control.  The  only  city 
where  anything  of  consequence  has  been  done  to  check 
the  spread  of  tuberculosis  from  man  to  man  is  New 
York.  An  inspection  of  the  death  rate  from  phthisis 
in  that  city  does  not  show  that  it  has  decreased  any 
more  rapidly  since  1895  than  it  did  before. 

It  is  not  necessary  in  this  paper  to  attempt  to  explain 
why  consumption  of  late  years  has  diminished  to  a  cer- 
tain extent,  but  it  is  generally  believed  to  be  due  to 
improved  living  on  the  part  of  our  people.  Better 
food,  better  clothing,  better  shelter  and  better  care  of 
the  sick  have  done  much  to  improve  the  general  health. 
Shorter  hours  for  work  and  more  time  spent  in  the 
open  air,  especially  by  women,  are  supposed  to  be  ele- 
ments in  causing  the  decrease. 

METHODS  OF  CONTROL  PROPOSED. 

Notification. 

The  writer  believes  that  one  of  the  most  important 
things  to  be  done  to  control  tuberculosis  is  to  study  still 
further  the  manner  in  which  the  disease  is  caused. 
Experimental  evidence  is  desired  on  many  points,  as 
has  been  referred  to  in  the  preceding  pages.  Clinical 
evidence  is  still  more  to  be  desired,  and  this  can  be  best 
obtained  by  government  investigation.  It  is  neces- 
sary to  study  a  very  large  number  of  cases  etiologically. 

4 


50  'rilK    STATE    CONTKOl^ 


If  for  no  other  purpose  than  to  give  an  ()])portnnity  for 
such  Htudy,  the  wtate  should  recpiire  the  report  of  all 
cases  of  tuhercnlosis.  It  is  just  as  important  to  study 
other  varieties  of  tuberculosis  as  it  is  to  study  ])hthisis. 
They  should  all  he  reported  as  is  recjuired  in  a  number 
of  existing  regulations.  There  has  been  considerable 
opposition  to  the  notification  of  this  disease,  but  it  is 
believed  that  this  has  been  due  largely  to  a  fear  that 
the  health  officer  would  interfere  with  the  family  phy- 
sician by  the  advice  which  he  miglit  give  to  the  patient. 
If  the  health  officer  does  not  so  interfere,  but  merely 
co-operates  with  the  physician,  it  is  believed  that  it 
will  not  l)e  any  more  difficult  to  secure  reports  of  tuber- 
culosis than  it  is  of  scarlet  fever.  It  should  be  the 
duty  of  the  health  officer  to  study  with  the  help  of  the 
attending  physician  the  causation  of  every  case  re- 
ported. Notification  presupposes  correct  diagnosis, 
and  therefore  every  state  and  city  should  certainly 
offer  facilities  for  tlie  examination  of  suspected 
sputum. 

Education. 

Every  sanitary  official  should  do  all  that  he  can  in 
every  way  to  spread  abroad  a  correct  knowledge  of  the 
causation  of  this  as  of  all  other  communicaljle  diseases. 
The  daily  press  usually  affords  valuable  assistance  in 
this.  Another  and  most  useful  means  of  educating 
people  is  by  means  of  circulars.  Every  local  health 
officer  shoidd  provide  himself  with  a  circular  explaining 
the  means  by  which  tuberculosis  is  spread,  and  describ- 
ing what  precautions  should  be  taken  to  prevent  its 
spread  from  one  person  to  another.  Such  a  circular 
should  be  prepared  with  very  great  care.     It  should  be 


OF    TIBEIICULOSIS.  51 

expressed  in  language  wliicli  can  be  readily  under- 
stood, and  it  is  very  important  that  it  should  contain 
no  statements  which  cannot  be  fully  substantiated. 
Impossible  things  should  not  be  required.  It  is  advis- 
able to  send  such  a  circular  to  every  family  in  the 
community,  stating  upon  it  that  this  is  done.  By 
so  doing,  no  one  can  be  offended.  It  is,  of  course,  very 
desirable  that  it  should  be  made  certain  that  the  family 
of  every  consumptive  should  receive  a  copy,  and  where 
there  is  a  physician  in  attendance,  the  circulars  may 
well  be  presented  by  him.  The  following  is  offered  as 
a  form  of  circular  for  general  distribution  : 

Consumption,  or  tuberculosis  of  the  lungs,  is  caused  by  the 
bacillus  of  tuberculosis,  a  kind  of  germ  or  microbe.  This  germ 
also  sometimes  causes  consumption  of  the  bowels  especially  in 
children,  and  sometimes  it  causes  disease  of  the  bones  or  of  other 
parts  of  the  body.  All  these  different  kinds  of  tuberculosis  are 
caused  by  the  germs  getting  into  the  body  in  one  way  or  another. 

Persons  who  have  consumption  usually  have  a  cough,  and  the 
matter  that  they  cough  up  contains  great  numbers  of  the  tiny 
germs  which  cause  the  disease.  If  the  sputum  or  matter  coughed 
up  gets  on  the  carpet,  floor,  furniture  or  clothing,  it  may  become 
dry  and  powdered,  and  float  about  in  the  air.  It  may  then  be 
breathed  in  by  another  person  and  thus  start  another  case  of  the 
disease. 

In  cases  of  consumption  the  face  and  hands  are  likely  to  become 
soiled  with  this  sputum,  and  cups,  spoons,  forks,  pencils,  handker- 
chiefs and  othfer  things  are  likely  to  be  infected  in  the  same  way.' 
If  other  persons  use  these  things  before  they  are  thoroughly 
washed  they  are  likely  to  catch  the  disease. 

In  cases  of  consumption  germs  are  not  given  off  by  ordinary 
breathing,  though  in  coughing  or  sneezing  they  may  be.  But 
there  is  probably  not  much  danger  from  this  except  to  a  person 
who  remains  much  in  close  contact  with  the  patient.  A  person 
who  has  consumption  should  always  sleep  alone. 

Cows  have  tuberculosis  as  frequently  as  human  beings  do. 
When  they  have  it  the  milk  is  likely  to  contain  the  germs  of  the 


52  'I'lIK    STATE    (CONTROL 

disease,  and  ])ers()iis  wlio  drink  tlie  milk  are  likely  to  have  tuber- 
culosis. No  milkman  ought  to  keep  a  tuberculous  cow  in  his 
herd.  He  ought  to  have  his  cows  examined  every  year  and  kill 
all  that  are  sick.  It  is  a  good  }>lan  for  all  persons  to  iiKjuire  of 
their  milkmen  as  to  whether  their  cows  have  been  tested  for  tuber- 
culosis. 

It  is  the  duty  of  every  ]»erson  who  has  consumption  to  take 
the  greatest  care  of  his  sputum,  for  it  is  this  that  is  particularly 
dangerous  to  others.  AVhen  at  home  he  should  always  spit  in  a 
cup  which  should  contain  water,  so  that  the  matter  may  not  dry. 
This  cup  should  be  emptied  into  the  water  closet  at  least  twice 
each  day  and  be  thoroughly  washed  in  boiling  water.  Paper 
spit  cups  may  l)e  used  which  can  l»e  burned.  These  are  furnished 
by  the  health  department  to  those  unable  to  pay  for  them.  When 
away  from  home  a  person  who  has  this  disease  should  sjiit  into  a 
pocket  flask  which  should  be  emptied  into  the  water  closet  and 
scalded  on  returning  home.  These  flasks  are  furnished  by  the 
health  dei)artment.  A  person  with  consumption  should  never 
spit  anywhere  except  into  a  spit  cup  or  flask.  He  should  take 
great  pains  not  to  get  sputum  on  his  hands  or  clothes.  Hand- 
kerchiefs used  to  wipe  the  lips  and  nose  may  be  carried  in  a  rub- 
ber-lined pocket  so  arranged  that  the  lining  can  be  removed  and 
washed.     Handkerchiefs  should  be  washed  frequently. 

As  the  face  and  hands  of  the  patient  are  certain  to  be  more  or 
less  infected  they  should  be  frequently  washed  in  hot  water  and 
soap.  It  is  best  for  a  mail  with  consumption  not  to  wear  either 
mustache  or  beard.  All  dishes  used  by  a  consumptive  should  be 
thoroughly  scalded  before  they  are  used  by  another.  The  bed 
clothes  and  night  clothes  of  a  person  with  consumption  should  be 
changed  often. 

AVhile  consumption  is  contagious  the  contagion  is  almost 
entirely  in  the  sputum,  and  if  this  is  taken  care  of  there  is  prob- 
ably not  much  danger  in  living  or  woi-king  with  a  consumptive. 

Consumption  is  not  always  a  fatal  disease.  A  great  many  per- 
sons who  have  the  disease  recover  from  it.  A  large  proportion 
of  cases  get  well  if  they  take  proper  care  of  themselves. 

When  a  person  with  consumption  has  been  sick  a  long  time  in 
one  room,  even  if  great  care  has  been  taken,  the  woodwork  and 


OF    TUBEKCT'LOSItS,  00 

furniture  are  liable  to  be  infected  and  should  be  tborougbly 
washed.  It  is  a  good  jilan  to  use  Avashing  soda  for  this.  The 
walls  should  be  repapered,  the  old  paper  being  taken  off.  Car- 
pets and  rugs  should  be  disinfected  with  steam. 

Conti'ol  of  Ex2)ectoration. 

As  has  been  said,  indiscriminate  spitting  is  a  nuis- 
ance and  should  Ije  stopped.  Spitting  in  pul)Uc  places 
should,  bj  statute  law,  Ije  made  an  offence.  In  place 
of  statute  law,  if  such  cannot  be  obtained,  every  muni- 
cipality should  have  a  regulation  of  this  kind  and 
enforce  it.  It  is  not  at  all  improbable  that  such  en- 
forcement mig-ht  have  considerable  influence  in  check- 
ing  the  spread  of  consumption. 

It  is  perhaps  possible  for  the  health  officer  to  do 
much  in  the  way  of  helping  the  individual  to  care  for 
his  expectoration.  The  plan  followed  in  New  York 
city  of  visiting  the  patient,  unless  the  attending  physi- 
cian requests  otherwise,  appears  to  be  a  good  one  ; 
and,  in  that  city,  has  been  productive  of  good  results. 
Subsequent  visits  shauld,  however,  be  made,  and  if  the 
inspector  has  tact  and  gains  the  confidence  of  the 
patient,  much  may  be  accomplished.  When  in  the 
house,  it  is  probable  that  the  best  thing  for  a  patient 
to  do  is  to  use  a  spit-cup.  These  are  made  in  various 
forms  and  one  made  by  Seabury  &  Johnson,  which  has  a 
paper  lining  which  can  be  removed,  and,  with  its  con- 
tents, burned,  is  a  very  good  one.  If  a  person  is  able 
to  be  about,  and,  particularly  if  he  is  alile  to  work,  he 
must  be  j)rovided  with  a  pocket  flask  and  perhaps, 
also,  with  some  sputum  receptacle  at  his  place  of  busi- 
ness. A  pocket  flask  made  of  aluminum  in  two  pieces, 
so  that  it  can  be  readily  taken  apart  and  cleaned,  has 
been  devised  by  Knopf  and  is  probably  the  best  that 


54  THE    STATE    CONTliOE 

can  be  obtained.  If  snch  a  flask  is  not  employed, 
handkerchiefs  may  be  used,  Ijut,  if  tliey  are,  the  pocket 
which  hohls  them  shonhl  have  a  rubber  lining  kept  in 
place  by  clamps.  Cups,  flasks  and  rubber  lining  should 
all  be  frequently  washed  and  scalded,  and  disinfected  if 
feasible.  If  the  consimiptive  can  l)e  induced  to  thus 
take  care  of  his  expectoration,  the  danger  of  his  trans- 
mitting the  disease  to  others  will  be  reduced  to  a  min- 
inuuii.  The  health  inspector,  either  by  himself  or  with 
the  assistance  of  the  attending  physician,  can  doubtless 
do  very  much  to  bring  about  this  desired  end,  but  it  is 
not,  by  any  means,  recommended  that  any  compulsion 
should  be  employed.  It  might  he  advisable  for  the 
municipality  to  furnish  the  spit  cups  and  flasks  to  those 
who  cannot  afford  them. 

Dismfection. 

Every  municipality  shoidd  be  ready  to  show  how 
apartments  can  be  disinfected  after  cases  of  consump- 
tion have  been  removed  from  them,  and  should  stand 
ready  to  disinfect  if  it  is  probable  that  it  will  not  other- 
wise be  properly  done.  It  might,  perhaps,  be  advisable 
to  require  Ijy  ordinance  that  all  premises  occupied  by 
consumptives  should  Ije  disinfected  before  they  are 
occupied  ]jy  others.  There  seems  to  be  little  doubt 
that  cleansing,  as  practiced  l)y  the  board  of  health  in 
New  York,  is  as  good  as  disinfection.  Disinfection,  if 
practiced,  should  always  be  hy  washing,  and  steaming, 
if  necessary  ;  gaseous  disinfection  should  not  be  relied 
upon. 

Hosjntals. 

There  is  no  question  in  the  mind  of  the  writer  that 
hospitals  furnish  the  Ijest  means  availaljle  for  the  state 


OF    TUBERCULOSIS.  55 

control  of  tuberculosis.  The  majority  of  consum})tive 
patients  are  among  the  poor  or  people  in  very  moderate 
circumstances.  It  is  extremely  difficult  for  such  to 
take  the  precautions  necessary  to  prevent  the  spread  of 
the  disease  ;  therefore  the  danger  is  greatest  from  this 
class  of  persons.  Unless  something  is  done  to  help 
them,  they  are  almost  certain  to  die.  If  they  can  be 
cared  for  in  suitable  sanatoria,  a  large  proportion  will 
recover,  provided  they,  are  taken  in  hand  early  enough 
in  the  disease.  Furthermore,  during  the  whole  time 
of  their  treatment,  there  will  be  no  danger  of  their 
infecting  others.  The  state  should  provide  hospitals 
for  the  curative  treatment  of  consumption  in  its  early 
stages.  The  consumptive  poor  who  are  suffering  from 
the  last  stages  of  the  disease  should  also  be  cared  for 
by  the  state.  Although  the  danger  to  be  apprehended 
from  this  class  is  not  great,  because  they  do  not  move 
about  so  freely,  and  although  the  chance  of  cure  is  slight, 
humanity  demands  that  they  should  receive  the  best  of 
care.  General  hospitals  very  properly  do  not  like  to 
receive  them,  but  they  are  frequently  obliged  to,  to  the 
danger  of  other  patients.  The  state  should  also  receive 
them,  as  well  as  incipient  cases,  in  its  hospitals  set  apart 
for  this  disease.  If  the  state  or  the  municipality  can 
only  do  one  thing  to  control  tuberculosis,  it  sliould 
establish  hospitals  for  consumptives. 

Control  of  the  Milk  Supply. 

As  has  been  shown,  the  evidence  is  pretty  strong 
that  a  consideralde  amount  of  tuberculosis  in  human 
beings  is  caused  by  the  ingestion  of  infected  milk. 
This  seems  to  be  sufficiently  certain  to  warrant  the 
making  of  a  very  strong  effort  to  prevent  the   sale   of 


56  THE    STATK    OONTitOL 

inilk  tVom  tuberculous  jinimals.  This  action  is  tlic 
more  warranted,  because  it  will  ultimately  l)e  to  the 
great  advantage  of  the  dairymen,  though  at  first  it 
may  cause  tliem  some  trouble  and  expense.  The  only 
certain  way  to  accomplish  the  desired  result  is  to  license 
all  dealers,  register  all  cows,  test  them  with  tuberculin, 
and  slaughter  all  that  are  infected.  Such  drastic 
measures  will  rarely  meet  with  popular  support,  l)ut 
must  l)e  carried  out  by  numicipalities  tliat  really  desire 
to  protect  their  milk  supply,  provided  they  can  secure 
the  necessary  legislative  authority.  If  this  is  impos- 
sible, as  it  frequently  is,  it  is  w^ortli  while  to  try  the 
Indianapolis  })lan  and  endeavor  to  encourage  dairymen 
to  voluntarily  eradicate  tuberculosis,  in  order  that  they 
may  secure  from  the  city  a  certificate  that  this  has 
been  done. 

The  Eradication  of  Ttfherciilosi.s  in  Cattle. 

From  a  review  of  what  has  been  done  and  attemj)ted 
in  this  line  in  the  United  States,  it  is  quite  evident  that 
it  is  impossible  to  successfully  carry  out  any  A^ery  dras- 
tic measures.  Little  can  be  done  without  the  co-opera- 
tion of  the  cattle  owner.  The  plan  which  seems  to  be 
most  successful  is  for  the  state  to  offer  its  assistance  in 
freeing  herds  from  tuberculosis.  If  the  owner  will 
agree  to  the  application  of  the  tuberculin  test,  and  will 
agree  to  improve  and  disinfect  his  stables,  as  required, 
and  thereafter  to  purchase  none  Ijut  tested  animals,  the 
state  should  test  his  herd,  slaughter  and  pay  for  all 
infected,  and  assist  in  disinfection,  and,  subsequently, 
ins|)ect  from  time  to  time  to  see  that  the  health  of  the 
herd  is  maintained.  It  is  believed  that  by  thus  grad- 
ually securing  healthy  herds  in  different  parts  of  the 


OF  'iri'.KifcrLosis.  57 

state,  enough  friends  will  finally  be  seciu'ed  for  the 
carrying  out  of  more  radical  measures  and  the  compul- 
sorv  cleansing  of  those  herds  whose  owners  still  per- 
sist in  maintaining  them  as  foci  of  the  disease.  The 
eradication  of  tuberculosis  in  animals,  except  as  it  is 
incidentally  involved  in  the  protection  of  municipal 
milk  siip])lies,  had  best  be  attempted  by  state  rather 
than  munici])al  aiithoi'ities. 

To  sunnnarize  what  seems  to  be  feasible  for  the  state 
at  present  to  attempt  in  the  way  of  control  of  tubercu- 
losis, it  may  be  said  : 

First.  Every  state  or  city  should  require  the  noti- 
fication of  the  disease,  and  offer  assistance  in  diag:nosis. 

Second.  State  and  municipal  health  authorities 
should  do  everything  possible  to  educate  the  people  by 
publications  and  by  verbal  instructions,  in  all  cases  co- 
operating with  and  never  superceding  the  attending 
physician. 

Thii'd.  The  spitting  habit  should  l)e  controlled  as 
much  as  possible,  and  effort  made  to  instruct  and  help 
the  consumptive  to  care  for  his  sputmn. 

Fourth.  Municipalities  should  assist  in  cleansing 
premises  occupied  b\'  consumptives. 

Fifth.  Tlie  state  or  the  municipality,  or  both,  should 
offer  hospital  facilities  for  the  care  of  this  disease. 

Sixth.  If ,  j)ublic  opinion  will  warrant,  no  milk 
should  be  sold  except  from  cows  tested  with  tuberculin. 
If  this  canncjt  l)e  done,  effort  should  l)e  made  to  induce 
dairymen  to  apply  this  test.  Such  work  must,  at 
present,  be  chiefly  done  by  municipalities. 

Seventh.  The  state,  by  means  of  state  officials, 
slioidd  strive  to  secure  the  co-operation  of  cattle  owners 
in  the  eradication  of  tuberculosis  from  their  herds,  and 
should  test  and  pay  for  slaughtered  animals. 


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